Test Bank psychiatric-mental health nursing 9th edition by Townsend and videbeck

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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Table of Contents Table of Contents 1 Chapter 01. The Concept of Stress Adaptation 2 Chapter 02. Mental Health/Mental Illness: Historical and Theoretical Concepts 9 Chapter 03. Psychopharmacology 20 Chapter 04. Concepts of Psychobiology 28 Chapter 05. Ethical and Legal Issues in Psychiatric/Mental Health Nursing 37 Chapter 06. Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health Nursing 47 Chapter 07. Relationship Development 54 Chapter 08. Therapeutic Communication 62 Chapter 09. The Nursing Process in Psychiatric/Mental Health Nursing 74 Chapter 10. Therapeutic Groups 85 Chapter 11. Intervention With Families 93 Chapter 12. Milieu Therapy - The Therapeutic Community 99 Chapter 13. Crisis Intervention 104 Chapter 14. Assertiveness Training 109 Chapter 15. Promoting Self-Esteem 117 Chapter 16. Anger/Aggression Management 123 Chapter 17. The Suicidal Client 130 Chapter 18. Behavior Therapy 139 Chapter 19. Cognitive Therapy 146 Chapter 20. Electroconvulsive Therapy 155 Chapter 21. The Recovery Model 162 Chapter 22. Neurocognitive Disorders 169 Chapter 23. Substance-Related and Addictive Disorders 175 Chapter 24. Schizophrenia Spectrum and Other Psychotic Disorders 186 Chapter 25. Depressive Disorders 197 Chapter 26. Bipolar and Related Disorders 208 Chapter 27. Anxiety, Obsessive-Compulsive, and Related Disorders 219 Chapter 28: Trauma and Stressor-Related Disorders 230 Chapter 29. Somatic Symptom and Dissociative Disorders 238 Chapter 30. Issues Related to Human Sexuality and Gender Dysphoria 244 Chapter 31. Eating Disorders 249 Chapter 32. Personality Disorders 257 Chapter 33. Children and Adolescents 269 Chapter 34. The Aging Individual 279 Chapter 35. Survivors of Abuse or Neglect 284 Chapter 36. Community Mental Health Nursing 290 Chapter 37. The Bereaved Individual 297 Chapter 38. Military Families 302

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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Chapter 01. The Concept of Stress Adaptation Multiple Choice 1. A client has experienced the death of a close family member and at the same time becomes unemployed.

This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data?

A. The client is experiencing severe distress and is at risk for physical and psychological illness.

B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness.

C. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports.

D. The client may view these losses as challenges and perceive them as opportunities.

ANS: C The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a clients life. However, positive coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 2. A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor?

A. Irrelevant B. Harm/loss C. Threatening D. Challenging ANS: D The client perceives the situation of job loss as a challenge and an opportunity for growth.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. Which client statement should alert a nurse that a client may be responding maladaptively to stress?

A. Ive found that avoiding contact with others helps me cope.

B. I really enjoy journaling; its my private time.

C. I signed up for a yoga class this week.

D. I made an appointment to meet with a therapist.

ANS: A Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems.

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A nursing student finds that she comes down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing?

A. Alarm reaction stage B. Stage of resistance C. Stage of exhaustion D. Fight-or-flight stage ANS: C At the stage of exhaustion, the students exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A school nurse is assessing a female high school student who is overly concerned about her appearance. The clients mother states, Thats not something to be stressed about! Which is the most appropriate nursing response?

A. Teenagers! They dont know a thing about real stress.

B. Stress occurs only when there is a loss.

C. When you are in poor physical condition, you cant experience psychological well-being.

D. Stress can be psychological. A threat to self-esteem may result in high stress levels.

ANS: D Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time?

A. Meditation B. Problem-solving training C. Relaxation D. Journaling ANS: B The student must assess his or her situation and determine the best course of action. Problem-solving training, by providing structure and objectivity, can assist in decision making.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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7. An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?

A. Encourage the student to use the alternative coping mechanism of relaxation exercises.

B. Complete the problem-solving process for the client.

C. Work through the problem-solving process with the client.

D. Encourage the client to keep a journal.

ANS: C During times of high anxiety and stress, clients will need more assistance in problem-solving and decision making.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A school nurse is assessing a distraught female high school student who is overly concerned because her parents cant afford horseback riding lessons. How should the nurse interpret the students reaction to her perceived problem?

A. The problem is endangering her well-being.

B. The problem is personally relevant to her.

C. The problem is based on immaturity.

D. The problem is exceeding her capacity to cope.

ANS: B Psychological stressors to self-esteem and self-image are related to how the individual perceives the situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all the advantages that other adolescents experience.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. Meditation has been shown to be an effective stress management technique. When meditation is effective, what should a nurse expect to assess?

A. An achieved state of relaxation B. An achieved insight into ones feelings C. A demonstration of appropriate role behaviors D. An enhanced ability to problem-solve ANS: A Meditation produces relaxation by creating a special state of consciousness through focused concentration.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 10. A distraught, single, first-time mother cries and asks a nurse, How can I go to work if I cant afford childcare? What is the nurses initial action in assisting the client with the problem-solving process?

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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A. Determine the risks and benefits for each alternative.

B. Formulate goals for resolution of the problem.

C. Evaluate the outcome of the implemented alternative.

D. Assess the facts of the situation.

ANS: D Before any other steps can be taken, accurate information about the situation must be gathered and assessed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. A nursing instructor is asking students about diseases of adaptation and when they are likely to occur.

Which student response indicates that learning has occurred?

A. When an individual has limited experience dealing with stress B. When an individual inherits maladaptive genes C. When an individual experiences existing conditions that exacerbate stress D. When an individuals physiological and psychological resources have become depleted ANS: D During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is the time when diseases of adaptation may occur.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 12. When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate?

A. Decreased resistance to disease B. Increased libido C. Decreased blood pressure D. Increased inflammatory response ANS: A In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at which time the bodys compensatory mechanisms no longer function effectively and diseases of adaptation occur. A decreased immune response is seen at this stage.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 13. Which symptom should a nurse identify as typical of the fight-or-flight response?

A. Pupil constriction B. Increased heart rate

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C. Increased salivation D. Increased peristalsis ANS: B During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions. OK KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 14. A nurse is evaluating a clients response to stress. What would indicate to the nurse that the client is experiencing a secondary appraisal of the stressful event?

A. When the individual judges the event to be benign B. When the individual judges the event to be irrelevant C. When the individual judges the resources and skills needed to deal with the event D. When the individual judges the event to be pleasurable ANS: C When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign-positive, and stressful.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 15. Research undertaken by Miller and Rahe in 1997 demonstrated a correlation between the effects of life change and illness. This research led to the development of the Recent Life Changes Questionnaire (RLCQ).

Which principle most limits the effectiveness of this tool?

A. Specific illnesses are not identified.

B. The numerical values associated with specific life events are randomly assigned C. Stress is viewed as only a physiological response.

D. Personal perception of the event is excluded.

ANS: D Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 16. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response?

A. Genetics have nothing to do with your temperament.

B. How you reacted to past experiences influences how you feel now.

C. If youre in good physical health, your stress level will be low.

D. Stress can always be avoided if appropriate coping mechanisms are employed.

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ANS: B Past experiences are occurrences that result in learned patterns that can influence an individuals current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 17. A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment.

Which of the following questions would best assist the nurse to determine the clients appraisal of the situation?

Select all that apply.

A. What resources have you used previously in stressful situations?

B. Have you ever experienced a similar stressful situation?

C. Who do you think is to blame for this situation?

D. Why do you think you were fired from your job?

E. What skills do you possess that might lead to gainful employment?

ANS: A, B, E These questions specifically address the clients coping resources and encourage the client to apply learning from past experiences. These questions also encourage the client to consider alternative methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather, encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to communication.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. A nurse is working with a client who has recently been under a great deal of stress. Which nursing recommendations would be most helpful when assisting the client in coping with stress? Select all that apply.

A. Enjoy a pet.

B. Spend time with a loved one.

C. Listen to music.

D. Focus on the stressors.

E. Journal your feelings.

ANS: A, B, C, E Focusing on the stressors is more likely to increase stress in the clients life. However, pets, music, journaling feelings, and healthy relationships have all been shown to decrease amounts of stress.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. A nurse is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety?

A. Diagnostic blood tests

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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B. Awareness of factors creating stress C. Relaxation exercises D. Identifying support systems ANS: B Although all of the above answers may be useful in the comprehensive management of stress, the initial step is awareness that stress is being experienced and awareness of factors that create stress.

KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 20. A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient are common initial biological responses to stress? Select all that apply.

A. Constricted pupils B. Watery eyes C. Unusual food cravings D. Increased heart rate E. Increased respirations ANS: B, D, E Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. Since dilated pupils rather than constricted pupils are related to Fight or Flight syndrome, this symptom should be assessed for other potential causes. Unusual food cravings have not been identified as a typical biological response to stress.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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Chapter 02. Mental Health/Mental Illness: Historical and Theoretical Concepts Multiple Choice 1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The clients appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the clients behaviors?

A. The clients behaviors demonstrate mental illness in the form of depression.

B. The clients behaviors are extensive, which indicates the presence of mental illness.

C. The clients behaviors are not congruent with cultural norms.

D. The clients behaviors demonstrate no functional impairment, indicating no mental illness.

ANS: D The nurse should assess that the clients daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the clients distress does not indicate a mental illness.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. At what point should the nurse determine that a client is at risk for developing a mental disorder?

A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria B. When maladaptive responses to stress are coupled with interference in daily functioning C. When the client communicates significant distress D. When the client uses defense mechanisms as ego protection ANS: B The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The clients ability to communicate distress would be considered a positive attribute.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents?

A. Reactions to stress are relative rather than absolute; individual responses to stress vary.

B. It is abnormal for identical twins to react differently to similar stressors.

C. Identical twins should share the same temperament and respond similarly to stress.

D. Environmental influences weigh more heavily than genetic influences on reactions to stress.

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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ANS: A Responses to stress are variable among individuals and may be influenced by perception, past experience, and environmental factors in addition to genetic factors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 4. A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, I work hard to provide for my family. I dont see why I cant drink to relax. The nurse recognizes the use of which defense mechanism?

A. Projection B. Rationalization C. Regression D. Sublimation ANS: B The nurse should recognize that the client is using rationalization, a common defense mechanism. The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. Which client should the nurse anticipate to be most receptive to psychiatric treatment?

A. A Jewish, female journalist B. A Baptist, homeless male C. A Catholic, black male D. A Protestant, Swedish business executive ANS: A The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely than men to seek treatment for mental health problems.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 6. A new psychiatric nurse states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement?

A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.

B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.

C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.

D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

ANS: A

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress.

A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?

A. Its just a routine part of our assessment. All clients are asked these same questions.

B. Why are you concerned about these types of questions?

C. Psychological factors, like excessive stress, have been found to affect medical conditions.

D. We can skip these questions, if you like. It isnt imperative that we complete this section.

ANS: C The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance 8. Which statement reflects a student nurses accurate understanding of the concepts of mental health and mental illness?

A. The concepts are rigid and religiously based.

B. The concepts are multidimensional and culturally defined.

C. The concepts are universal and unchanging.

D. The concepts are unidimensional and fixed.

ANS: B The student nurse should understand that mental health and mental illness are multidimensional and culturally defined. It is important for nurses to be aware of cultural norms when evaluating a clients mental state.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 9. A mental health technician asks the nurse, How do psychiatrists determine which diagnosis to give a patient? Which of these responses by the nurse would be most accurate?

A. Psychiatrists use pre-established criteria from the APAs Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

B. Hospital policy dictates how psychiatrists diagnose mental disorders.

C. Psychiatrists assess the patient and identify diagnoses based on the patients unhealthy responses and contributing factors.

D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from.

ANS: A

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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The DSM-5 is an organized manual describing mental disorders and the criteria that determine whether a given diagnosis is appropriate. It is published by the American Psychiatric Association (APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes nursing rather than medical diagnosis.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. The nurse is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction?

A. Learning is best when anxiety is moderate to severe.

B. Learning is enhanced when anxiety is mild.

C. Panic level anxiety helps the nurse teach better.

D. Severe anxiety is characterized by intense concentration and enhances the attention span.

ANS: B Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness of the environment. Learning is enhanced. As anxiety increases, attention span decreases and learning becomes more difficult.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Health Promotion and Maintenance 11. Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM-5?

A. Somatic symptom disorders B. Grief responses C. Psychosis D. Bipolar disorder ANS: A Somatic symptom disorder is characterized by preoccupation with physical symptoms for which there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety about health concerns or illness.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?

A. The employee assertively confronts the boss B. The employee leaves the staff meeting to work out in the gym C. The employee criticizes a coworker D. The employee takes the boss out to lunch ANS: C The client using the defense mechanism of displacement would criticize a coworker after being confronted by

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 13. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, I know she wants me. This statement reflects which defense mechanism?

A. Displacement B. Projection C. Rationalization D. Sublimation ANS: B The nurse should determine that the clients statement reflects the defense mechanism of projection. Projection refers to the attribution of ones unacceptable feelings or impulses to another person. When the client passes the blame of the undesirable feelings, anxiety is reduced. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism?

A. Displacement B. Projection C. Reaction formation D. Sublimation ANS: C The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. Which nursing statement about the concept of neuroses is most accurate?

A. An individual experiencing neurosis is unaware that he or she is experiencing distress.

B. An individual experiencing neurosis feels helpless to change his or her situation.

C. An individual experiencing neurosis is aware of psychological causes of his or her behavior.

D. An individual experiencing neurosis has a loss of contact with reality.

ANS: B

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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The nurse should understand that the concept of neuroses includes the following characteristics. The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 16. Which nursing statement about the concept of psychoses is most accurate?

A. Individuals experiencing psychoses are aware that their behaviors are maladaptive.

B. Individuals experiencing psychoses experience little distress.

C. Individuals experiencing psychoses are aware of experiencing psychological problems.

D. Individuals experiencing psychoses are based in reality.

ANS: B The nurse should understand that the client with psychoses experiences little distress, because of his or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 17. When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?

A. Hiding liquor bottles in a closet B. Yelling at their son for slouching in his chair C. Burning dinner on purpose D. Saying to the spouse, I dont drink too much!

ANS: D The nurse should associate the client statement I dont drink too much! with the use of the defense mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the feelings associated with it is using the defense mechanism of denial.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?

A. If only we could have tried again, things might have worked out.

B. I am so mad that the children and I had to put up with him as long as we did.

C. Yes, it was a difficult relationship, but I think I have learned from the experience.

D. I still dont have any appetite and continue to lose weight.

ANS: C

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

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The nurse should recognize that the client is in the acceptance stage of grief. During this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 19. A nurse is performing a mental health assessment on an adult client. According to Maslows hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?

A. Maintaining a long-term, faithful, intimate relationship B. Achieving a sense of self-confidence C. Possessing a feeling of self-fulfillment and realizing full potential D. Developing a sense of purpose and the ability to direct activities ANS: C The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslows hierarchy of needs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity 20. According to Maslows hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?

A. A client rudely complaining about limited visiting hours B. A client exhibiting aggressive behavior toward another client C. A client stating that no one cares D. A client verbalizing feelings of failure ANS: B The nurse should immediately intervene when a client exhibits aggressive behavior toward another client.

Safety and security are considered lower-level needs according to Maslows hierarchy of needs and must be fulfilled before other, higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 21. Which is an example of the ego defense mechanism of regression?

A. A mother blames the teacher for her childs failure in school.

B. A teenager becomes hysterical after seeing a friend killed in a car accident.

C. A woman wants to marry a man exactly like her beloved father.

D. An adult throws a temper tantrum when he does not get his own way.

ANS: D Regression is the retreating to an earlier level of development and the comfort measures associated with that level of functioning.

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KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 22. Which is the most significant consequence of the excessive use of defense mechanisms?

A. The superego will be suppressed.

B. Emotions will be experienced intensely.

C. Learning and the ability to grow will be enhanced.

D. Problem-solving will be limited.

ANS: D Defense mechanisms become maladaptive when they are used by an individual to such a degree that there is interference with the ability to deal with reality, effective interpersonal relations, or occupational performance.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 23. A husband accuses his wife of infidelity. Which situation would indicate to the nurse the husbands use of the ego defense mechanism of projection?

A. The husband cries and stamps his feet, demanding that his wife be true to her marriage vows.

B. The husband ignores the wifes continued absence from the home.

C. The husband has already admitted to having an affair with a coworker.

D. The husband takes out his marital frustrations through employee abuse.

ANS: C Projection is the attribution of feelings or impulses unacceptable to ones self to another person. In this situation, the husband attributes his infidelity to his wife.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 24. Which should the nurse recognize as a DSM-5 disorder?

A. Obesity B. Generalized anxiety disorder C. Hypertension D. Grief ANS: B The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety disorder, somatic symptom disorder, and dissociative disorders.

KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 25. A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health?

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A. Mental health is the absence of any stressors.

B. Mental health is successful adaptation to stressors in the internal and external environment.

C. Mental health is incongruence between thoughts, feelings, and behavior D. Mental health is a diagnostic category in the DSM-5.

ANS: B Several definitions of mental health exist, but this definition highlights concepts of successful adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms.

KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 26. Most cultures label behavior as mental illness on the basis of which of the following criteria?

A. Incomprehensibility and cultural relativity B. Strength of character and ethics C. Goal directedness and high energy D. Creativity and good coping skills ANS: A Incomprehensibility and cultural relativity are most often the criteria used to define whether something is labeled mental illness. The other identified behaviors would be more associated with health than illness.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 27. Which should the nurse recognize as an example of the defense mechanism of repression?

A. A student aware of the need to study for tomorrows test goes to a movie instead.

B. A woman whose son was killed in Iraq does not believe the military report.

C. A man who is unhappily married goes to school to become a marriage counselor.

D. A woman was raped when she was 12 and no longer remembers the incident.

ANS: D Repression is the involuntary blocking of unpleasant feelings and experiences from ones awareness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 28. Which of the following statements should a nurse recognize as true about defense mechanisms? Select all that apply.

A. They are employed when there is a threat to biological or psychological integrity.

B. They are controlled by the id and deal with primal urges.

C. They are used in an effort to relieve mild to moderate anxiety.

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D. They are protective devices for the superego.

E. They are mechanisms that are characteristically self-deceptive.

ANS: A, C, E Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity, in an effort to relieve mild to moderate anxiety. Because they redirect focus, they are characteristically selfdeceptive.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 29. A nurse is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptoms might the client demonstrate? Select all that apply.

A. Fidgeting B. Laughing inappropriately C. Palpitations D. Nail biting E. Extremely limited attention span ANS: A, B, D The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 30. Which of the following are cultural aspects of mental illness? Select all that apply.

A. Local or cultural norms define pathological behavior.

B. The higher the social class the greater the recognition of mental illness behaviors.

C. Psychiatrists typically see patients when the family can no longer deny the illness.

D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion.

ANS: A, B, C The fewer ties that a group has with mainstream society, the greater the likelihood of a negative response by society to mental illness. Coercive treatments and involuntary hospitalizations are more common in this population.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity .

31. How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply.

A. It informs the nurse of accurate and reliable medical diagnosis.

Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017)

B. It represents progress toward a more holistic view of mindbody.

C. It provides a framework for interdisciplinary communication.

D. It provides a template for nursing care plans.

E. It provides a framework for communication with the client.

ANS: A, B, C The DSM-5 is useful in the practice of psychiatric nursing because it facilitates comprehensive evaluation of the client. In addition, it encourages a holistic view and provides a framework for interdisciplinary communication.

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Chapter 03. Psychopharmacology Multiple Choice 1. The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics: A. Remain in the system longer B. Act more quickly to reduce delusions C. Produce fewer extrapyramidal effects D. Are risk free for neuroleptic malignant syndrome (NMS) ANS: C Atypical antipsychotics produce less D2blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quicklyto reduce delusions. The atypicals are not risk free for NMS. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a: A. 30 mm Hg decrease in blood pressure reading B. Respiratory rate of 24 respirations per minute C. Temperature reading of 104° F D. Pulse rate of 70 beats per minute ANS: C Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms?

A. Decreased dopamine at receptor sites B. Blockade of histamine C. Cholinergic blockade D. Adrenergic blocking ANS: C Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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4. Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)?

A. Grimacing and lip smacking B. Falling asleep in the chair and refusing to eat lunch C. Experiencing muscle rigidity and tremors D. Having excessive salivation and drooling ANS: A TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A nurse administers a medication that potentiates the action of GABA. Which finding would be expected?

A. Reduced anxiety B. Improved memory C. More organized thinking D. Fewer sensory perceptual alterations ANS: A Increased levels of GABA reduce anxiety, thus any potentiation of GABA action should result in anxiety reduction. Memory enhancement is associated with acetylcholine and substance P. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 6. On the basis of current knowledge of neurotransmitter effects, a nurse could anticipate that the treatment plan for a patient with memory difficulties might include medications designed to: A. inhibit GABA. B. increase dopamine at receptor sites.

C. decrease dopamine at receptor sites.

D. prevent destruction of acetylcholine.

ANS: D Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory.

GABA is known to affect anxiety level rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson’s disease rather than improving memory.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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7. A patient has disorganized thinking associated with schizophrenia. A PET scan would most likely show dysfunction in which part of the brain?

A. Temporal lobe B. Cerebellum C. Brainstem D. Frontal lobe ANS: D The frontal lobe is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the: A. parasympathetic nervous system.

B. sympathetic nervous system.

C. reticular activating system.

D. medulla oblongata.

ANS: A Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system.

When acetylcholine action is inhibited by anticholinergic drugs, parasympathetic symptoms such as blurred vision, dry mouth, constipation, and urinary retention appear. The functions of the sympathetic nervous system, the reticular activating system, and the medulla oblongata are not affected by anticholinergics.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 9. The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: A. increased concentration of neurotransmitter in the synaptic gap.

B. decreased concentration of neurotransmitter in the synaptic gap.

C. destruction of receptor sites.

D. limbic system stimulation.

ANS: A If the reuptake of a substance is inhibited, it accumulates in the synaptic gap and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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10. A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action?

A. Dopamine-blocking effects B. Anticholinergic effects C. Endocrine-stimulating effects D. Ability to stimulate spinal nerves ANS: A Medication that blocks dopamine often produces disturbances of movement such as akathisia because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A nurse assesses that a patient demonstrates anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter?

A. GABA B. Histamine C. Acetylcholine D. Norepinephrine ANS: D Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for “fight or flight.” GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours ago. The patient will need teaching about a drug from which group?

A. Tricyclic antidepressants B. Antimanic drugs C. Benzodiazepines D. Antipsychotic drugs ANS: C Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression.

Antimanic drugs are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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13. A patient is hospitalized for severe depression. Of the medications listed below, a nurse can expect to provide the patient with teaching about: A. clozapine (Clozaril) B. chlordiazepoxide (Librium) C. tacrine (Cognex) D. fluoxetine (Prozac) ANS: D Fluoxetine is an SSRI. It is an antidepressant that blocks the reuptake of serotonin with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine is used to treat Alzheimer’s disease.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A patient hospitalized with a mood disorder has an elevated unstable mood, aggressiveness, agitation, talkativeness, and irritability. A nurse begins care planning based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): A. anticholinergic.

B. mood stabilizer C. psychostimulant D. antidepressant ANS: B The symptoms describe a manic attack. Mania is effectively treated by the antimanic drug lithium and selected anticonvulsants such as carbamazepine, valproic acid, and lamotrigine. No drugs from the other classifications listed are effective in the treatment of mania.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A drug causes muscarinic receptor blockade. A nurse will assess the patient for: A. gynecomastia B. pseudoparkinsonism C. orthostatic hypotension D. dry mouth ANS: D Muscarinic receptor blockade includes atropine-like side effects such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with alpha-1 antagonism.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A patient tells a nurse, "My doctor prescribed Paxil [paroxetine] for my depression. I suppose I’ll have side

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effects like I had when I was taking Tofranil [imipramine]." The nurse’s reply should be based on the knowledge that paroxetine is a(n): A. tricyclic antidepressant B. MAOI C. selective serotonin reuptake inhibitor D. selective norepinephrine reuptake inhibitor ANS: C Paroxetine is a selective serotonin reuptake inhibitor and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A nurse can anticipate anticholinergic side effects are likely when a patient is taking: A. lithium (Lithobid).

B. isperidone (Risperdal).

C. buspirone (BuSpar).

D. fluphenazine (Prolixin).

ANS: D Fluphenazine, a first-generation antipsychotic, exerts muscarinic blockade, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: A. hypotensive shock.

B. hypertensive crisis.

C. cardiac dysrhythmia.

D. cardiogenic shock ANS: B Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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19. A patient has taken many conventional antipsychotic drugs over years. The health care provider, concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: A. are less costly.

B. have higher potency.

C. are more readily available.

D. produce fewer motor side effects.

ANS: D Atypical antipsychotic drugs often exert their action on the limbic system rather than the basal ganglia. The limbic system is not involved in motor disturbances. Atypical antipsychotics are not more readily available.

They are not considered to be of higher potency; rather, they have different modes of action. Atypical antipsychotic drugs tend to be more expensive.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 20. A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha-1 receptors because the patient may experience: A. increased psychotic symptoms.

B. a hypertensive crisis.

C. orthostatic hypotension.

D. severe appetite disturbance.

ANS: C Sympathetic mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of alpha-1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Patients should be taught ways of minimizing this phenomenon.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving: A. lithium (Lithobid) B. clozapine (Clozaril) C. fluoxetine (Prozac) D. venlafaxine (Effexor) ANS: A Lithium is known to alter electrical conductivity, producing cardiac dysrhythmias, tremor, convulsions, polyuria, edema, and other symptoms of fluid and electrolyte imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block.

Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.

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Chapter 04. Concepts of Psychobiology Multiple Choice 1. A depressed client states, I have a chemical imbalance in my brain. I have no control over my behavior.

Medications are my only hope to feel normal again. Which nursing response is appropriate?

A. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors.

B. Because biological factors are the sole cause of depression, medications will improve your mood.

C. Environmental factors have been shown to exert the most influence in the development of depression.

D. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment).

ANS: A The nurse should advise the client that medications are one treatment approach to address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression and the potential for psychological treatments to have a positive impact on biological factors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance 2. A client diagnosed with major depressive disorder asks, What part of my brain controls my emotions?

Which nursing response is appropriate?

A. The occipital lobe governs perceptions, judging them as positive or negative.

B. The parietal lobe has been linked to depression.

C. The medulla regulates key biological and psychological activities.

D. The limbic system is largely responsible for ones emotional state.

ANS: D The nurse should explain to the client that the limbic system is largely responsible for ones emotional state.

This system is often called the emotional brain and is associated with feelings, sexuality, and social behavior.

The occipital lobes are the area of visual reception and interpretation. Somatosensory input (touch, taste, temperature, etc.) occurs in the parietal lobes. The medulla contains vital centers that regulate heart rate and reflexes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance 3. Which part of the nervous system should a nurse identify as playing a major role during stressful situations?

A. Peripheral nervous system B. Somatic nervous system C. Sympathetic nervous system D. Parasympathetic nervous system ANS: C

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The nurse should identify that the sympathetic nervous system plays a major role during stressful situations.

The sympathetic nervous system prepares the body for the fight-or-flight response. The parasympathetic nervous system is dominant when an individual is in a nonstressful state.

KEY: Cognitive Level: Comprehension | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 4. Which client statement reflects an understanding of the effect of circadian rhythms on a persons ability to function?

A. When I dream about my mothers horrible train accident, I become hysterical.

B. I get really irritable during my menstrual cycle.

C. Im a morning person. I get my best work done in the a.m.

D. Every February, I tend to experience periods of sadness.

ANS: C By stating, I am a morning person, the client demonstrates an understanding that circadian rhythms may influence a variety of regulatory functions, including the sleepwake cycle, regulation of body temperature, and patterns of activity. Most humans follow a 24-hour cycle that is largely affected by light and darkness.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 5. Which types of adoption studies should a nurse recognize as providing useful information for the psychiatric community?

A. Studies in which children with mentally ill biological parents are raised by adoptive parents who were mentally healthy B. Studies in which children with mentally healthy biological parents are raised by adoptive parents who were mentally ill C. Studies in which monozygotic twins from mentally ill parents were raised separately by different adoptive parents D. Studies in which monozygotic twins were raised together by mentally ill biological parents E. All of the above ANS: E The nurse should determine that all of the studies could possibly benefit the psychiatric community. The studies may reveal research findings relating genetic links to mental illness. Adoption studies allow comparisons to be made of the influences of the environment versus genetics.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 6. Six months after her husband and children were killed in a car accident, a client is diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which study perspective?

A. The study of neuroendocrinology B. The study of psychoimmunology C. The study of diagnostic technology

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D. The study of neurophysiology ANS: B Psychoimmunology is the branch of medicine that studies the effects of social and psychological factors on the functioning of the immune system. Studies of the biological response to stress hypothesize that individuals become more susceptible to physical illness following exposure to stressful stimuli.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 7. A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior?

A. Dendrites B. Axons C. Neurotransmitters D. Synapses ANS: C The nurse should recognize that neurotransmitters play an essential function in the role of human emotion and behavior. Neurotransmitters are targeted and affected by many psychotropic medications.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 8. An instructor is teaching nursing students about neurotransmitters. Which term best explains the process of how neurotransmitters released into the synaptic cleft may return to the presynaptic neuron?

A. Regeneration B. Reuptake C. Recycling D. Retransmission ANS: B The nursing instructor should best explain that the process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is by reuptake. Reuptake is the process by which neurotransmitters are stored for reuse.

KEY: Cognitive Level: Comprehension | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 9. A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse should associate this response with which neurotransmitter?

A. Acetylcholine B. Dopamine C. Serotonin D. Norepinephrine

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ANS: D The nurse should associate the neurotransmitter norepinephrine with the fight-or-flight response.

Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is associated with the regulation of mood, cognition, perception, locomotion, sleep, and arousal.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 10. A client is admitted to a psychiatric unit with the diagnosis of catatonic schizophrenia. Which of the clients neurotransmitters should a nurse expect to be elevated?

A. Serotonin B. Dopamine C. Gamma-aminobutyric acid (GABA) D. Histamine ANS: B The nurse should expect that elevated dopamine levels might be an attributing factor to the clients current level of functioning. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 11. A clients wife of 34 years dies unexpectedly. The client cries often and becomes socially isolated. The clients therapist stresses the importance of proper sleep, nutrition, and exercise. What is the best rationale for the therapists advice?

A. The therapist is using an interpersonal approach.

B. The client has an alteration in neurotransmitters.

C. It is routine practice to remind clients about nutrition, exercise, and rest.

D. The client is susceptible to illness due to effects of stress on the immune system.

ANS: D The therapists advice should be based on the knowledge that the client has been exposed to stressful stimuli and is at an increased risk of developing illness due to the effects of stress on the immune system. The study of this branch of medicine is called psychoimmunology.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 12. Which mental illness should a nurse identify as being associated with a decrease in prolactin hormone level?

A. Major depression B. Schizophrenia C. Anorexia nervosa D. Alzheimers disease

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ANS: B Although the exact mechanism is unknown, there may be some correlation between decreased levels of the hormone prolactin and the diagnosis of schizophrenia. Some studies have shown an inverse relationship between prolactin concentrations and symptoms of schizophrenia.

KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 13. Which cerebral structure should a nursing instructor describe to students as the emotional brain?

A. The cerebellum B. The limbic system C. The cortex D. The left temporal lobe ANS: B The limbic system is often referred to as the emotional brain. The limbic system is largely responsible for ones emotional state and is associated with feelings, sexuality, and social behavior.

KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 14. A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?

A. Acute mania B. Schizophrenia C. Anorexia nervosa D. Alzheimers disease ANS: C A nurse should understand that research has found a correlation between abnormal levels of growth hormone and anorexia nervosa. The growth hormone is responsible for growth in children, as well as continued protein synthesis throughout life.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 15. A client is admitted to an emergency department experiencing memory deficits and decreased motor function. What alteration in brain chemistry should a nurse correlate with the presentation of these symptoms?

A. Abnormal levels of serotonin B. Decreased levels of dopamine C. Increased levels of norepinephrine D. Decreased levels of acetylcholine ANS: D The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine. Acetylcholine is a major effector chemical of the autonomic nervous system. Functions of

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acetylcholine include sleep regulation, pain perception, the modulation and coordination of movement, and memory.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 16. A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness?

A. Mania B. Schizophrenia C. Anxiety D. Depression ANS: D The nurse should recognize that a decrease in norepinephrine levels would play a significant role in generating the symptoms of depression. The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 17. Which client diagnosis should a nurse associate with a decrease in gamma-aminobutyric acid (GABA)?

A. Alzheimers disease B. Schizophrenia C. Panic disorder D. Depression ANS: C The nurse should associate a decrease in GABA with panic disorder. Enhancement of the GABA system is the mechanism of action by which benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the GABA system are also associated with movement disorders and epilepsy.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 18. A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness?

A. Schizophrenia B. Depression C. Body dysmorphic disorder D. Parkinsons disease ANS: A The nurse should expect that an increase in dopamine activity might play a significant role in the development of schizophrenia. Dopamine functions include regulation of emotions, coordination, and voluntary decisionmaking ability. Increased dopamine activity is also associated with mania.

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KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 19. A nursing instructor is teaching about the monoamine category of neurotransmitters. Which student statement indicates that learning about the function of norepinephrine has occurred?

A. Norepinephrine functions to regulate movement, coordination, and emotions.

B. Norepinephrine functions to regulate mood, cognition, and perception.

C. Norepinephrine functions to regulate arousal, libido, and appetite.

D. Norepinephrine functions to regulate pain, inflammatory response, and wakefulness.

ANS: B The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, and cardiovascular function. Norepinephrine has also been implicated in certain mood disorders such as depression and mania, anxiety states, and schizophrenia.

KEY: Cognitive Level: Comprehension | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 20. A student nurse is studying the effect of the drug isocarboxazid (Marplan) on neurobiology. The student should recognize that the neurotransmitter serotonin is catabolized by which enzyme?

A. Glycosyltransferase B. Peptidase C. Polymerase D. Monoamine oxidase ANS: D Serotonin that is not returned to be stored in the axon terminal vesicles is catabolized by the enzyme monoamine oxidase. A monoamine oxidase inhibitor, such as Marplan, inhibits this catabolism, providing more available serotonin at the neuron synapse.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity 21. During a sleep study, a delta rhythm has been recorded for a client experiencing sleep apnea. The nurse recognizes that which characteristic is associated with this rhythm, and what stage of sleep activity would be documented?

A. Delta rhythm is a period of dozing, occurring in stage 1 of sleep activity.

B. Delta rhythm is a period of deep and restful sleep, occurring in stage 3 of sleep activity.

C. Delta rhythm is a period of relaxed waking, occurring in stage 0 of sleep activity.

D. Delta rhythm is a period of dreaming, occurring in stage 2 of sleep activity.

ANS: B Stage 3delta rhythm is a period of deep and restful sleep. Muscles are relaxed, heart rate and blood pressure fall, and breathing slows. No eye movement occurs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:

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Physiological Integrity Multiple Response 22. Which of the following information should a nurse include when explaining causes of anorexia nervosa to a client? Select all that apply.

A. There is a possible correlation between abnormal secretion of growth hormone and anorexia nervosa.

B. There is a possible correlation between antidiuretic hormone levels and anorexia nervosa.

C. There is a possible correlation between low levels of gonadotropin and anorexia nervosa.

D. There is a possible correlation between increased levels of prolactin and anorexia nervosa.

E. There is a possible correlation between altered levels of oxytocin and anorexia nervosa.

ANS: A, C The nurse should explain to the client that there is a possible correlation between anorexia nervosa and decreased levels of growth hormones and gonadotropin. Anorexia nervosa has also been correlated with increased cortisol levels.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 23. Which of the following symptoms should a nurse associate with increased levels of thyroid-stimulating hormone (TSH) in a newly admitted client? Select all that apply.

A. Depression B. Fatigue C. Increased libido D. Mania E. Hyperexcitability ANS: A, B The nurse should associate depression and fatigue with increased levels of TSH. TSH is only increased when thyroid levels are low, as in the diagnosis of hypothyroidism. In addition to depression and fatigue, other symptoms such as decreased libido, memory impairment, and suicidal ideation are also associated with chronic hypothyroidism.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 24. Which of the following symptoms should a nurse expect to assess in a client experiencing elevated levels of thyroid hormone? Select all that apply.

A. Emotional lability B. Depression C. Insomnia D. Restlessness E. Apathy

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ANS: A, C, D The nurse should assess the client with an elevated level of thyroid hormone for evidence of emotional lability, insomnia, and restlessness. Elevated levels of thyroid hormone indicate a diagnosis of hyperthyroidism or Graves disease, which is also associated with the symptoms of irritability, anxiety, and weight loss.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

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Chapter 05. Ethical and Legal Issues in Psychiatric/Mental Health Nursing Multiple Choice 1. In response to a students question regarding choosing a psychiatric specialty, a charge nurse states, Mentally ill clients need special care. If I were in that position, Id want a caring nurse also. From which ethical framework is the charge nurse operating?

A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism ANS: B The charge nurse is operating from a Christian ethics framework. A basic principle in Christian ethics is to do unto others as you would have them do unto you. Kantianism states that decisions should be based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made with a focus on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.

KEY: Cognitive Level: Analysis | Integrated Processes: Caring | Client Need: Safe and Effective Care Environment 2. During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework?

A. I would want to be treated in a caring manner if I were mentally ill.

B. This job will pay the bills, and the workload is light enough for me.

C. I will be happy caring for the mentally ill. Working in Med/Surg kills my back.

D. It is my duty in life to be a psychiatric nurse. It is the right thing to do.

ANS: B The applicants comment reflects an ethical egoism framework. This framework promotes the idea that decisions are based on what is good for the individual and may not take the needs of others into account.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 3. Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurses coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworkers lack of involvement?

A. Taking no action is still considered an action by the coworker.

B. Taking no action releases the coworker from ethical responsibility.

C. Taking no action is advised when potential adverse consequences are foreseen.

D. Taking no action is acceptable, because the coworker is only a bystander.

ANS: A

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The coworkers lack of involvement can be interpreted as an action taken. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. Although the coworker may be struggling with ethical decision making, he or she has witnessed another nurse dispensing medication outside of the scope of practice; therefore, from a legal perspective, this should be reported.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 4. Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit managers policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit managers policy preserve?

A. Justice B. Autonomy C. Veracity D. Beneficence ANS: B The unit managers policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 5. Which is an example of an intentional tort?

A. A nurse fails to assess a clients obvious symptoms of neuroleptic malignant syndrome.

B. A nurse physically places an irritating client in four-point restraints.

C. A nurse makes a medication error and does not report the incident.

D. A nurse gives patient information to an unauthorized person.

ANS: B A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. Examples of unintentional torts are malpractice and negligence actions.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 6. An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?

A. Verbally redirect the client, and then limit one-on-one interaction.

B. Involve the hospitals security division as soon as possible.

C. Notify the client that documenting personal staff information is against hospital policy.

D. Continue professional attempts to establish a positive working relationship with the client.

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ANS: D The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 7. Which statement should a nurse identify as correct regarding a clients right to refuse treatment?

A. Clients can refuse pharmacological but not psychological treatment.

B. Clients can refuse any treatment at any time.

C. Clients can refuse only electroconvulsive therapy (ECT).

D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

ANS: D The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 8. Which client should a nurse identify as a potential candidate for involuntarily commitment?

A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is a danger to self and requires emergency treatment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 9. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the clients wishes?

A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities ANS: C The nurse would have the right to medicate a client against his or her wishes if the client physically attacks

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another client. This client poses a significant risk to safety and is incapable of making rational choices. The clients refusal to accept treatment can be challenged because the client is endangering the safety of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 10. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations?

A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the clients therapist ANS: A The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 11. A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle?

A. Autonomy B. Beneficence C. Nonmaleficence D. Justice ANS: A The nurse should provide the information to support the clients autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 12. An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation?

A. Autonomy B. Beneficence C. Nonmaleficence D. Justice ANS: D The nurse should determine that the ethical principle of justice has been violated by the physicians actions. The

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principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 13. Which situation contradicts the ethical principle of veracity?

A. A nurse provides a client with outpatient resources to benefit recovery.

B. A nurse refuses to give information to a physician who is not responsible for the clients care.

C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.

D. A nurse treats all of the clients equally regardless of illness severity.

ANS: C The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to ones duty to always be truthful and not intentionally deceive or mislead clients.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 14. A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent?

A. The client is paranoid.

B. The client is 87 years old.

C. The client incorrectly reports his or her spouses name, the date, and the time of day.

D. The client relies on his or her spouse to interpret the information.

ANS: C The nurse should question the validity of informed consent when the client incorrectly reports the spouses name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 15. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate?

A. Allow the client to decline the medication and document.

B. Tell the client that if the medication is refused, hospitalization will occur.

C. Arrange with a relative to add medication to the clients morning orange juice.

D. Call for help to hold the client down while the injection is administered.

ANS: A It is ethically and legally appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The clients right to refuse treatment should be upheld unless the refusal puts the client or others in harms way.

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KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. Which situation exemplifies both assault and battery?

A. The nurse becomes angry, calls the client offensive names, and withholds treatment.

B. The nurse threatens to tie down the client and then does so against the clients wishes.

C. The nurse hides the clients clothes and medicates the client to prevent elopement.

D. The nurse restrains the client without just cause and communicates this to family.

ANS: B The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 17. A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?

A. The client is placed in seclusion.

B. The client is placed in a geriatric chair with tray.

C. The client is placed in soft Posey restraints.

D. The client is monitored by an ankle bracelet.

ANS: D The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 18. A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the clients approved call list. What law has the nurse broken?

A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law ANS: C The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

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19. An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment teams next action?

A. State law determines how long a psychiatric facility can hold a client.

B. Federal law determines if the client is competent.

C. The clients family involvement will determine if discharge is possible.

D. Hospital policies will determine treatment team actions.

ANS: A Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment 20. A client is concerned that information given to the nurse remains confidential. Which is the nurses best response?

A. Your information is confidential. It will be kept just between you and me.

B. I will share the information with staff members only with your approval.

C. If the information impacts your care, I will need to share it with the treatment team.

D. You can make the decision whether your physician needs this information or not.

ANS: C Basic to the psychiatric clients hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the clients care.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 21. The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true?

A. Competency is determined with a clients compliance with treatment.

B. Refusal of medication can initiate an incompetency hearing leading to forced medications.

C. A competent client has the ability to make reasonable judgments and decisions.

D. Competency is a medical determination made by the clients physician.

ANS: C A competent individuals cognition is not impaired to an extent that would interfere with decision making.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 22. A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction?

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A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing.

B. The Nurse Practice Act lists education requirements for licensure and reciprocity.

C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs).

D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.

ANS: C The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 23. Which is an accurate description of a common law?

A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints.

B. A common law would be invoked to deal with a nurse who touches a client without the clients consent.

C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both.

D. A common law would be invoked to deal with a nurses refusal to provide care for a specific client.

ANS: D Common laws apply to a body of principles that evolve from court decisions resolving various controversies.

Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law.

Stealing is governed by criminal law.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 24. The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience?

A. Administering a tranquilizing medication before applying the restraints B. Talking to the client at brief but regular intervals while the client is restrained C. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements ANS: B Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 25. There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment?

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A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan ANS: C The criteria for involuntary emergency commitment include danger to self and/or others. Of the four clients considered, the client who is delusional and has a plan to kill his wife meets this criterion as a danger to others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 26. What is the legal significance of a nurses action when a nurse threatens a demanding client with restraints?

A. The nurse can be charged with assault.

B. The nurse can be charged with negligence.

C. The nurse can be charged with malpractice.

D. The nurse can be charged with beneficence.

ANS: A Assault is an act that results in a persons genuine fear and apprehension that he or she will be touched without consent.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 27. In the situation presented, which nursing intervention constitutes false imprisonment?

A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained.

B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion.

C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.

D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.

ANS: B False imprisonment is the deliberate and unauthorized commitment of a person within fixed limits by the use of verbal or physical means. Seclusion should only be used in an emergency situation to prevent harm after least restrictive means have been unsuccessfully attempted.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment Multiple Response 28. After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria would enable a physician to

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consider involuntary commitment? Select all that apply.

A. Being dangerous to others B. Being homeless C. Being disruptive to the community D. Being gravely disabled and unable to meet basic needs E. Being suicidal ANS: A, D, E The physician could consider involuntary commitment when a client is being dangerous to others, is gravely disabled, or is suicidal. If the client is determined to be mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. A hospital administrator may give permission for involuntary commitment when time does not permit court intervention.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment

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Chapter 06. Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health Nursing Multiple Choice 1. An African American youth, growing up in an impoverished neighborhood, presents in the emergency department with bruises to his face, chest, and arms. He appears to be upset, is speaking in a dialect that is difficult for the nurse to understand, and is standing within 6 inches of the nurses personal space. What cultural consideration should a nurse identify as playing a role in this youths behavior?

A. African Americans frequently speak in different tongues when they are upset.

B. Most African Americans have learned to be aggressive when they have to see a health professional.

C. African Americans tend to use dialects and invasion of personal space to intimidate others.

D. Some African Americans speak in a dialect that is different from standard English and tend toward smaller personal space than that of the dominant culture.

ANS: D The nurse needs to recognize that a tendency toward smaller personal space and the use of dialects different from Standard English are cultural variables and dont necessarily imply aggressive or disrespectful behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. Northern European Americans value punctuality, hard work, and the acquisition of material possessions and status. A nurse should recognize that these values may contribute to which form of mental disorders?

A. Dissociative disorders B. Neurocognitive disorders C. Stress-related disorders D. Schizophrenia spectrum disorders ANS: C Northern European American values, such as punctuality, hard work, and acquisition of material possessions, may place this group at risk for stress-related disorders when individuals struggle to meet societal demands.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 3. A community health nurse is planning a health fair at a local shopping mall. Which middle-class socioeconomic cultural group should the nurse anticipate would most value preventive medicine and primary health care?

A. Northern European Americans B. Native Americans C. Latino Americans D. African Americans ANS: A

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Northern European Americans, especially those who achieve middle-class socioeconomic status, place the most value on preventative medicine and primary health care. This value is most likely related to this groups educational level and financial capability. Many members of the Native American, Latino American, and African American subgroups value folk medicine practices.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 4. Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture?

A. Extremes of emotional expression prevent accurate assessment of this culture.

B. Suspicion of Western civilization has resulted in minimal cultural research.

C. The small size of this subpopulation makes research virtually impossible.

D. The Asian American culture includes individuals from many different countries.

ANS: D The Asian American culture includes peoples and descendents from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands. Within this culture there are vast differences in values, religious practices, languages, and attitudes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 5. A Latin American woman refuses to participate in an assertiveness training group. Which cultural belief should a nurse identify as most likely to have influenced this clients decision?

A. Future orientation causes the client to devalue assertiveness skills.

B. Decreased emotional expression makes it difficult to be assertive.

C. Assertiveness techniques may not be aligned with the clients definition of the female role.

D. Religious prohibitions prevent the clients participation in assertiveness training.

ANS: C The nurse should identify that the Latin American womans refusal to participate in an assertiveness training group may be influenced by the Latin American cultural definition of the female role. Latin Americans place a high value on the male-dominated family. The father usually possesses the ultimate authority.

KEY: Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Psychosocial Integrity 6. A Latino American man refuses to acknowledge responsibility for hitting his wife, stating instead, Its the mans job to keep his wife in line. Which cultural belief may be associated with this clients behavior?

A. Traditional Latino American families are male dominated with clear malefemale role distinctions.

B. Religious tenets of Latino American culture support the use of violence within a marriage.

C. Latino American families are female dominated and the mother possesses ultimate authority.

D. Marriage dynamics are controlled by dominant females in Latin American families.

ANS: A Traditional Latino American families are male dominated with clear malefemale role distinctions and may

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impact the clients perception about whether or not striking his wife is physical abuse. The nurse should also recognize that cultural beliefs do no exempt one from adhering to state and federal laws with regard to assault and battery.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 7. When working with clients of any culture, which action should a nurse avoid?

A. Maintaining eye contact, based on cultural norms B. Assuming that all individuals who share a culture or ethnic group are similar C. Supporting the client in participating in cultural and spiritual rituals D. Using an interpreter to clarify communication ANS: B The nurse should avoid assuming that all individuals who share a culture or ethnic group are similar. This action constitutes stereotyping and must be avoided. Within each culture, many variations and subcultures exist. Clients should be treated as individuals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. To effectively care for Asian American clients, a nurse should be aware of which cultural norm?

A. Obesity and alcoholism are common problems.

B. Older people maintain positions of authority within the culture.

C. Milk is a staple in the Asian American diet.

D. Asian Americans are likely to seek psychiatric help.

ANS: B To effectively care for clients of the Asian American culture, the nurse should be aware that older people in this culture maintain positions of authority. Obesity and alcoholism are low among Asian Americans. Milk is seldom consumed because a majority of Asian Americans are lactose intolerant. In the Asian culture, psychiatric illness is often believed to be out-of-control behavior and would be considered shameful to individuals and families.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. A Native American client is admitted to an emergency department (ED) with an ulcerated toe secondary to uncontrolled diabetes mellitus. The client refuses to talk to a physician unless a shaman is present. Which nursing intervention is most appropriate?

A. Assist the client in contacting a shaman of his choice.

B. Explain to the client that voodoo medicine will not heal the ulcerated toe.

C. Ask the client to explain what the shaman can do that the physician cannot.

D. Inform the client that refusing treatment is a clients right.

ANS: A

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The most appropriate nursing intervention would be to facilitate meeting the clients need to have a shaman present. The nurse should understand that in the Native American culture, religion and health-care practices are often intertwined. The shaman, a medicine man, may confer with physicians regarding the care of a client.

Research supports the importance of both health-care systems in the overall wellness of Native American clients.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation |Client Need: Psychosocial Integrity 10. When planning care for a Latino American client, the nurse should be aware of which cultural influence that may impact access to health care?

A. The root doctor may be the first contact made when illness is encountered.

B. The yin and yang practitioner may be the first contact made when illness is encountered.

C. The shaman may be the first contact made when illness is encountered.

D. The curandero may be the first contact made when illness is encountered.

ANS: D The nurse should understand that some Latino Americans may initially contact a curandero when illness is encountered. The curandero is the folk healer who is believed to have a gift from God for healing the sick.

Treatments often include supernatural rituals, prayers, magic, practical advice, and indigenous herbs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. In what way should a nurse expect a traditional Asian American client to view mental illness?

A. Mental illness relates to uncontrolled behaviors that bring shame to the family.

B. Mental illness is a curse from God related to immoral behaviors.

C. Mental illness is cured by home remedies based on superstitions.

D. Mental illness is cured by hot and cold herbal remedies.

ANS: A The nurse should expect that traditional Asian Americans are most likely to view mental illness as uncontrolled behavior that brings shame to the family. It is often more acceptable for mental distress to be expressed as physical ailments.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. Which cultural considerations should a nurse identify with Western European Americans?

A. They are present-time oriented and perceive the future as Gods will.

B. They value youth, and older adults are commonly placed in nursing homes.

C. They are at high risk for alcoholism due to a genetic predisposition.

D. They are future oriented and practice preventive health care.

ANS: A The nurse should identify that most Western European Americans are present oriented and perceive the future

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as Gods will. Older adults are held in positions of respect and are often cared for in the home instead of nursing homes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 13. A nurse should recognize that clients who have a history of missed or late medical appointments are most likely to come from which cultural group?

A. Northern European Americans B. Asian Americans C. Native Americans D. Jewish Americans ANS: C The nurse should recognize that Native American clients might have a history of missed or late medical appointments. Many Native Americans are not ruled by the clock. The concept of time is casual and focused on the present.

KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Psychosocial Integrity 14. During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action?

A. The nurses action should be evaluated as unacceptable due to breech of cultural norms.

B. The nurses action should be evaluated as empathetic, encouraging expression of feelings.

C. The nurses action should be evaluated as the technique of offering self.

D. The nurses action should be evaluated as inappropriate due to poor timing.

ANS: A The nurses action should be evaluated as unacceptable due to breech of cultural norms. During communication, Arab Americans stand close together, maintain steady eye contact, and may touch the others hand or shoulder but only between members of the same sex.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 15. A nursing instructor is teaching about cultural characteristics. Which statement by the student indicates the need for further instruction?

A. All cultures communicate freely within their group.

B. All cultures embrace light therapeutic touch.

C. All cultures view the importance of timeliness differently.

D. All cultures display biological variations.

ANS: B Not all cultures embrace light therapeutic touch. In the Native American culture, if a hand is offered to another

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it may be accepted with a light touch; however, in the Asian culture, touching during communication has been historically considered unacceptable. This student statement indicates the need for further instruction.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 16. A nurse is preparing to establish a therapeutic relationship with a grieving family from China. Which nursing intervention would be considered most appropriate?

A. Touch each member lightly, as this enhances the communication process.

B. Direct questions to the young males of the family, as they maintain positions of authority.

C. Avoid direct eye contact, as it implies rudeness.

D. Remain objective and empathetic, as Asians express feelings freely.

ANS: C In the Asian culture, eye contact is often avoided, as it connotes rudeness and lack of respect.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. Which cultural group is correctly matched with the disease process for which this group is most susceptible?

A. African Americans are susceptible to lactose intolerance.

B. Western European Americans are susceptible to malaria.

C. Arab Americans are susceptible to sickle cell disease.

D. Jewish Americans are susceptible to thalassemia.

ANS: C A number of genetic diseases are more common in the Arab American population, including sickle cell disease, tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, parasitic infestations, thalassemia, and cardiovascular disease.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 18. When interviewing a client of a different culture, which of the following questions should a nurse consider asking? Select all that apply.

A. Would using perfume products be acceptable?

B. Who may be expected to be present during the client interview?

C. Should communication patterns be modified to accommodate this client?

D. How much eye contact should be made with the client?

E. Would hand shaking be acceptable?

ANS: B, C, D, E

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When interviewing a client from a different culture, the nurse should consider who might be with the client during the interview, modifications of communication patterns, amount of eye contact, and hand-shaking acceptability, since these are cultural variables.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. A female nurse is caring for a traditional Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? Select all that apply.

A. Limited touch is acceptable only between members of the same sex.

B. Conversing individuals of this culture stand far apart and do not make eye contact.

C. Devout Muslim men may not shake hands with women.

D. The man is the head of the household and women take on a subordinate role.

E. In traditional culture, men are responsible for the education of their children.

ANS: A, C, D When planning effective care for this client, the nurse should be aware that limited touch within this culture is acceptable only between members of the same sex, that devout Muslim men may not shake hands with women, and that women are subordinate to the man, who is the head of household. Conversing individuals of this culture stand close together and maintain eye contact. Arab American women are responsible for the education of the children.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 20. Because of cultural characteristics, in which of the following cultural groups would a nurses assessment of mood and affect be most challenging? Select all that apply.

A. Arab Americans B. Native Americans C. Latino Americans D. Western European Americans E. Asian Americans ANS: B, E The nurse should expect that both Native Americans and Asian Americans might be difficult to assess for mood and affect. In both cultures, expressing emotions is difficult. Native Americans are encouraged to not communicate private thoughts. Asian Americans may have a reserved public demeanor and may be perceived as shy or uninterested.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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Chapter 07. Relationship Development Multiple Choice 1. What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client?

A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the clients length of stay D. To establish personal goals for the interaction ANS: A The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding ones own attitudes, values, and beliefs is called self-awareness.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an admission interview.

When the nurse postpones the admission interview, verbally assures safety, and provides a warm meal, he or she is promoting which of the following?

A. Sympathy B. Trust C. Veracity D. Manipulation ANS: B The nurse is promoting trust by postponing the admission interview, assuring safety, and providing a warm meal. Trust implies a feeling of confidence that a person is reliable and sincere and has integrity and veracity.

Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. Which is the best nursing action when a client demonstrates transference toward a nurse?

A. Promoting safety and immediately terminating the relationship with the client B. Encouraging the client to ignore these thoughts and feelings C. Immediately reassigning the client to another staff member D. Helping the client to clarify the meaning of the current nurseclient relationship ANS: D The nurse should respond to a clients transference by clarifying the meaning of the nurseclient relationship, based on the current situation. Transference occurs when the client unconsciously displaces feelings toward the nurse about a person from the past. The nurse should assist the client in separating the past from the present.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 4. What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?

A. Acknowledge the clients actions and generate alternative behaviors.

B. Establish rapport and develop treatment goals.

C. Attempt to find alternative placement.

D. Explore how thoughts and feelings about this client may adversely impact care.

ANS: B The priority nursing action during the orientation phase of the nurseclient relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurseclient relationship.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. Which client response should a nurse expect during the working phase of the nurseclient relationship?

A. The client gains insight and incorporates alternative behaviors.

B. The client and nurse establish rapport and mutually develop treatment goals.

C. The client explores feelings related to reentering the community.

D. The client explores personal strengths and weaknesses that impact behaviors.

ANS: A The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurseclient relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. What should be the nurses primary goal during the preinteraction phase of the nurseclient relationship?

A. To evaluate goal attainment and ensure therapeutic closure B. To establish trust and formulate a contract for intervention C. To explore self-perceptions D. To promote client change ANS: C The nurses primary goal of the preinteraction phase should be to explore self-perceptions. The nurse should be aware of how any preconceptions may affect his or her ability to care for individual clients. Another goal of the preinteraction phase is to obtain available client information.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

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7. Which phase of the nurseclient relationship begins when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals?

A. Preinteraction B. Orientation C. Working D. Termination ANS: B The orientation phase is when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals. There are four phases of relationship development: preinteraction, orientation, working, and termination.

KEY: Cognitive Level: Comprehension | Integrated Process: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurseclient relationship?

A. I cant bear the thought of leaving here and failing.

B. I might have a hard time working with you. You remind me of my mother.

C. I cant tell my husband how I feel; he wouldnt listen anyway.

D. Im not sure that I can count on you to protect my confidentiality.

ANS: C The nurse should identify that the client statement I cant tell my husband how I feel; he wouldnt listen anyway reflects resistance to change, which is a common behavior in the working phase of the nurseclient relationship.

The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. A client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy?

A. You are feeling very depressed. I felt the same way when I decided to leave my husband.

B. I can understand you are feeling depressed. It was a difficult decision. Ill sit with you.

C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?

D. I know this is a difficult time for you. Would you like a prn medication for anxiety?

ANS: A The nurses statement, You are feeling very depressed. I felt the same when I decided to leave my husband, is a nontherapeutic statement that conveys sympathy. Sympathy implies that the nurse shares what the client is feeling and by this personal expression alleviates the clients distress.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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10. A mother who has learned that her child was killed in a tragic car accident states, I cant bear to go on with my life. Which nursing statement conveys empathy?

A. This situation is very sad, but time is a great healer.

B. You are sad, but you must be strong for your other children.

C. Once you cry it all out, things will seem so much better.

D. It must be horrible to lose a child; Ill stay with you until your husband arrives.

ANS: D The nurses response, It must be horrible to lose a child; Ill stay with you until your husband arrives, conveys empathy to the client. Empathy is the ability to see the situation from the clients point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. If an individual is two-faced, which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing?

A. Respect B. Genuineness C. Sympathy D. Rapport ANS: B The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individuals ability to be open and honest and maintain congruence between what is felt and what is communicated.

Genuineness is essential to establishing trust in a relationship.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 12. On which task should a nurse place priority during the working phase of relationship development?

A. Establishing a contract for intervention B. Examining feelings about working with a particular client C. Establishing a plan for continuing aftercare D. Promoting the clients insight and perception of reality ANS: D The nurse should place priority on promoting the clients insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 13. A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client

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responds, Do you want to be my girlfriend? Which nursing response is most appropriate?

A. You are upset now. It would be best if you go to your room until you feel better.

B. Remember, we have a professional relationship. Are you feeling uncomfortable?

C. We have discussed this before. I am not allowed to date clients.

D. I think you should discuss your fantasies with your therapist.

ANS: B The nurse should promote the clients insight and perception of reality by confirming appropriate roles in the nurseclient relationship and identifying what is troubling the client in this situation.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?

A. The client is using manipulation to receive secondary gain.

B. The client is using the defense mechanism of denial.

C. The client is having trouble terminating the relationship.

D. The client is using splitting as a way to remain dependent on the nurse.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. When a client feels sadness and loss, behaviors to delay termination may become evident.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 15. According to Peplau, which nursing action demonstrates the nurses role as a resource person?

A. The nurse balances a safe therapeutic environment to increase the clients sense of belonging.

B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness.

C. The nurse monitors the administration of medications and watches for signs of cheeking.

D. The nurse explains, in language the client can understand, information related to the clients health care.

ANS: D According to Peplau, a resource person provides specific answers to questions usually formulated with relation to a larger problem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 16. According to Peplau, which nursing intervention is most appropriate when the nurse is functioning in the role of a surrogate?

A. The nurse functions as a nurturing parent in order to build a trusting relationship.

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B. The nurse plays cards with a small group of clients.

C. The nurse discusses childhood events that may affect personality development.

D. The nurse provides a safe social environment.

ANS: A According to Peplau, when a client is acutely ill, he or she may incur the role of infant or child, while the nurse is perceived as the mother surrogate.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. As the client and nurse move from the orientation stage to the working stage of the therapeutic relationship, which is the nurses most therapeutic statement?

A. I want to assure you that I will maintain your confidentiality.

B. A long-term goal for someone your age would be to develop better job skills.

C. Which identified problems would you like for us to initially address?

D. I think first we need to focus on your relationship issues.

ANS: C When moving on a continuum from the orientation to working phase of the nurseclient relationship, the clients identified goals are addressed through mutual therapeutic work to promote client behavioral change.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 18. What is the main goal of the working phase of the nurseclient therapeutic relationship?

A. Role modeling to improve interaction with others B. Resolution of the clients problems C. Using therapeutic communication to clarify perceptions D. Helping the client access outpatient treatment ANS: B The goal of the working phase of the nurseclient therapeutic relationship is to resolve client problems by promoting behavioral change.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. Which client statement may indicate a transference reaction?

A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life.

B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor.

C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself.

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D. My mother is the source of my problems. She has always told me what to do and what to say.

ANS: A Transference occurs when a client unconsciously displaces or transfers to the nurse feelings formed toward a person from the past.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 20. Which nursing action demonstrates the role of the teacher in a therapeutic milieu?

A. The nurse implements a self-affirmation exercise during a one-to-one client interaction.

B. The nurse holds a group meeting to present common side effects of psychiatric medications.

C. The nurse introduces the concept of fair play while playing cards with a group of clients.

D. The nurse models adaptive and effective coping mechanisms with clients on the psychiatric unit.

ANS: B The nurse, in the role of teacher, identifies learning needs and provides information required by the client or family to improve the clients health.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 21. Which client statement indicates that termination of the therapeutic nurseclient relationship has been handled successfully?

A. I know I can count on you for continued support.

B. I am looking forward to discharge, but I am surprised that we will no longer work together.

C. Reviewing the changes that have happened during our time together has helped me put things in perspective.

D. I dont know how comfortable I will feel when talking to someone else.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. Bringing a therapeutic conclusion to the relationship occurs when progress has been made toward attainment of mutually set goals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 22. When is self-disclosure by the nurse appropriate in a therapeutic nurseclient relationship?

A. When it is judged that the information may benefit the nurse and client B. When the nurse has a duty to warn C. When the nurse feels emotionally indebted toward the client D. When it is judged that the information may benefit the client ANS: D

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Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurses needs.

KEY: Cognitive Level: Knowledge | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity Multiple Response 23. The nurseclient therapeutic relationship includes which of the following characteristics? Select all that apply.

A. Meeting the psychological needs of the nurse and the client B. Ensuring therapeutic termination C. Promoting client insight into problematic behavior D. Collaborating to set appropriate goals E. Meeting both the physical and psychological needs of the client ANS: B, C, D, E The nurseclient therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. The nurses psychological needs should not be addressed within the nurseclient relationship.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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Chapter 08. Therapeutic Communication Multiple Choice 1. Which therapeutic communication technique is being used in this nurseclient interaction?

Client: When I get angry, I get into a fistfight with my wife or I take it out on the kids.

Nurse: I notice that you are smiling as you talk about this physical violence.

A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations ANS: D The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 2. Which therapeutic communication technique is being used in this nurseclient interaction?

Client: My father spanked me often.

Nurse: Your father was a harsh disciplinarian.

A. Restatement B. Offering general leads C. Focusing D. Accepting ANS: A The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the clients statement has been heard and understood.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. Which therapeutic communication technique is being used in this nurseclient interaction?

Client: When I am anxious, the only thing that calms me down is alcohol.

Nurse: Other than drinking, what alternatives have you explored to decrease anxiety?

A. Reflecting B. Making observations C. Formulating a plan of action

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D. Giving recognition ANS: C The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the clients poor coping choice, may serve to prevent anger or anxiety from escalating.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a general lead?

A. Do you know why you are here?

B. Are you feeling depressed or anxious?

C. Yes, I see. Go on.

D. Can you chronologically order the events that led to your admission?

ANS: C The nurses statement, Yes, I see. Go on, is an example of the therapeutic communication technique of a general lead. Offering a general lead encourages the client to continue sharing information.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. A nurse states to a client, Things will look better tomorrow after a good nights sleep. This is an example of which communication technique?

A. The therapeutic technique of giving advice B. The therapeutic technique of defending C. The nontherapeutic technique of presenting reality D. The nontherapeutic technique of giving false reassurance ANS: D The nurses statement, Things will look better tomorrow after a good nights sleep, is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the clients feelings.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?

A. What occurred prior to the rape, and when did you go to the emergency department?

B. What would you like to talk about?

C. I notice you seem uncomfortable discussing this.

D. How can we help you feel safe during your stay here?

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ANS: B The nurses statement, What would you like to talk about? is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the clients role in the interaction.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations?

A. You appear to be talking to someone I do not see.

B. Please describe what you are seeing.

C. Why do you continually look in the corner of this room?

D. If you hum a tune, the voices may not be so distracting.

ANS: A The nurse is making an observation when stating, You appear to be talking to someone I do not see. Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurses perceptions.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening?

A. S B. O C. L D. E E. R ANS: B The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER. The acronym SOLER includes sitting squarely facing the client (S), open posture when interacting with the client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity 9. An instructor is correcting a nursing students clinical worksheet. Which instructor statement is the best example of effective feedback?

A. Why did you use the clients name on your clinical worksheet?

B. You were very careless to refer to your client by name on your clinical worksheet.

C. I noticed that you used the clients name in your written process recording. That is a breach of confidentiality.

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D. It is disappointing that after being told, youre still using client names on your worksheet.

ANS: C The instructors statement, I noticed that you used the clients name in your written process recording, is an example of effective feedback. Feedback is a method of communication to help others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice or criticism.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, Im so proud of you for being assertive. You are so good! Which communication technique has the leader employed?

A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations ANS: A The group leader has employed the nontherapeutic technique of giving approval. Giving approval implies that the nurse has the right to pass judgment on whether the clients ideas or behaviors are good or bad. This creates a conditional acceptance of the client.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. What is the purpose of a nurse providing appropriate feedback?

A. To give the client good advice B. To advise the client on appropriate behaviors C. To evaluate the clients behavior D. To give the client critical information ANS: D The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst?

A. Why do you continue to alienate your peers by your angry outbursts?

B. You accomplish nothing when you lose your temper like that.

C. Showing your anger in that manner is very childish and insensitive.

D. During group, you raised your voice, yelled at a peer, and slammed the door.

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ANS: D The nurse is providing appropriate feedback when stating, During group, you raised your voice, yelled at a peer, and slammed the door. Giving appropriate feedback involves helping the client consider a modification of behavior. Feedback should give information to the client about how he or she is perceived by others.

Feedback should not be evaluative or be used to give advice.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Psychosocial Integrity 13. A client diagnosed with dependent personality disorder states, Do you think I should move from my parents house and get a job? Which nursing response is most appropriate?

A. It would be best to do that in order to increase independence.

B. Why would you want to leave a secure home?

C. Lets discuss and explore all of your options.

D. Im afraid you would feel very guilty leaving your parents.

ANS: C The most appropriate response by the nurse is, Lets discuss and explore all of your options. In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. When interviewing a client, which nonverbal behavior should a nurse employ?

A. Maintaining indirect eye contact with the client B. Providing space by leaning back away from the client C. Sitting squarely, facing the client D. Maintaining open posture with arms and legs crossed ANS: C When interviewing a client, the nurse should employ the nonverbal behavior of sitting squarely, facing the client. Facilitative skills for active listening can be identified by the acronym SOLER. SOLER includes sitting squarely facing the client (S), open posture when interacting with a client (O), leaning forward toward the client (L), establishing eye contact (E), and relaxing (R).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 15. A mother rescues two of her four children from a house fire. In an emergency department, she cries, I should have gone back in to get them. I should have died, not them. Which of the following responses by the nurse is an example of reflection?

A. The smoke was too thick. You couldnt have gone back in.

B. Youre feeling guilty because you werent able to save your children.

C. Focus on the fact that you could have lost all four of your children.

D. Its best if you try not to think about what happened. Try to move on.

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ANS: B The best response by the nurse is, Youre experiencing feelings of guilt because you werent able to save your children. This response utilizes the therapeutic communication technique of reflection, which identifies a clients emotional response and reflects these feelings back to the client so that they may be recognized and accepted.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 16. A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually.

This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?

A. Everyone diagnosed with OCD needs to control their ritualistic behaviors.

B. It is important for you to discontinue these ritualistic behaviors.

C. Why are you asking for help if you wont participate in unit therapy?

D. Lets figure out a way for you to attend unit activities and still wash your hands.

ANS: D The most appropriate statement by the nurse is, Lets figure out a way for you to attend unit activities and still wash your hands. This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship or increasing the clients anxiety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process?

A. Weve discussed past coping skills. Lets see if these coping skills can be effective now.

B. Please tell me in your own words what brought you to the hospital.

C. This new approach worked for you. Keep it up.

D. I notice that you seem to be responding to voices that I do not hear.

ANS: A This is an example of the therapeutic communication technique of formulating a plan of action. By the use of this technique the nurse can help the client plan in advance to deal with a stressful situation, which may prevent anger and/or anxiety from escalating to an unmanageable level.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Psychosocial Integrity 18. A client tells the nurse, I feel bad because my mother does not want me to return home after I leave the hospital. Which nursing response is therapeutic?

A. Its quite common for clients to feel that way after a lengthy hospitalization.

B. Why dont you talk to your mother? You may find out she doesnt feel that way.

C. Your mother seems like an understanding person. Ill help you approach her.

D. You feel that your mother does not want you to come back home?

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ANS: D This is an example of the therapeutic communication technique of restatement. Restatement is the repeating of the main idea that the client has verbalized. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or clarify if necessary.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. A clients younger daughter is ignoring curfew. The client states, Im afraid she will get pregnant. The nurse responds, Hang in there. Dont you think she has a lot to learn about life? This is an example of which communication block?

A. Requesting an explanation B. Belittling the client C. Making stereotyped comments D. Probing ANS: C This is an example of the nontherapeutic communication block of making stereotyped comments. Clichs and trite expressions are meaningless in a therapeutic nurseclient relationship.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 20. Which nursing statement is a good example of the therapeutic communication technique of giving recognition?

A. You did not attend group today. Can we talk about that?

B. Ill sit with you until it is time for your family session.

C. I notice you are wearing a new dress and you have washed your hair.

D. Im happy that you are now taking your medications. They will really help.

ANS: C This is an example of the therapeutic communication technique of giving recognition. Giving recognition acknowledges and indicates awareness. This technique is more appropriate than complimenting the client, which reflects the nurses judgment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 21. A client is trying to explore and solve a problem. Which nursing statement would be an example of verbalizing the implied?

A. You seem to be motivated to change your behavior.

B. How will these changes affect your family relationships?

C. Why dont you make a list of the behaviors you need to change.

D. The team recommends that you make only one behavioral change at a time.

ANS: A

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This is an example of the therapeutic communication technique of verbalizing the implied. Verbalizing the implied puts into words what the client has only implied or said indirectly.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 22. The nurse says to a newly admitted client, Tell me more about what led up to your hospitalization. What is the purpose of this therapeutic communication technique?

A. To reframe the clients thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation ANS: C This is an example of the therapeutic communication technique of exploring. The purpose of exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 23. A student nurse tells the instructor, Im concerned that when a client asks me for advice I wont have a good solution. Which should be the nursing instructors best response?

A. Its scary to feel put on the spot by a client. Nurses dont always have the answer.

B. Remember, clients, not nurses, are responsible for their own choices and decisions.

C. Just keep the clients best interests in mind and do the best that you can.

D. Set a goal to continue to work on this aspect of your practice.

ANS: B Giving advice tells the client what to do or how to behave. It implies that the nurse knows what is best and that the client is incapable of any self-direction. It discourages independent thinking.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 24. A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication?

A. Touch carries a different meaning for different individuals.

B. Touch is often used when deescalating volatile client situations.

C. Touch is used to convey interest and warmth.

D. Touch is best combined with empathy when dealing with anxious clients.

ANS: A Touch can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 25. Which nursing statement is a good example of the therapeutic communication technique of focusing?

A. Describe one of the best things that happened to you this week.

B. Im having a difficult time understanding what you mean.

C. Your counseling session is in 30 minutes. Ill stay with you until then.

D. You mentioned your relationship with your father. Lets discuss that further.

ANS: D This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 26. After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled.

The client swears at the nurse and states, You are incompetent! Which is the nurses best response?

A. Do you believe that I was the cause of your blood test being canceled?

B. I see that you are upset, but I feel uncomfortable when you swear at me.

C. Have you ever thought about ways to express anger appropriately?

D. Ill give you some space. Let me know if you need anything.

ANS: B This is an example of the appropriate use of feedback. Feedback should be directed toward behavior that the client has the capacity to modify.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 27. During a nurseclient interaction, which nursing statement may belittle the clients feelings and concerns?

A. Dont worry. Everything will be alright.

B. You appear uptight.

C. I notice you have bitten your nails to the quick.

D. You are jumping to conclusions.

ANS: A This nursing statement is an example of the nontherapeutic communication block of belittling feelings.

Belittling feelings occurs when the nurse misjudges the degree of the clients discomfort, suggesting a lack of empathy and understanding.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 28. A client on an inpatient psychiatric unit tells the nurse, I should have died, because I am totally worthless.

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In order to encourage the client to continue talking about feelings, which should be the nursing initial response?

A. How would your family feel if you died?

B. You feel worthless now, but that can change with time.

C. Youve been feeling sad and alone for some time now?

D. It is great that you have come in for help.

ANS: C This nursing statement is an example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 29. Which nursing response is an example of the nontherapeutic communication block of requesting an explanation?

A. Can you tell me why you said that?

B. Keep your chin up. Ill explain the procedure to you.

C. There is always an explanation for both good and bad behaviors.

D. Are you not understanding the explanation I provided?

ANS: A This nursing statement is an example of the nontherapeutic communication block of requesting an explanation.

Requesting an explanation is when the client is asked to provide the reason for thoughts, feelings, behaviors, and events. Asking why a client did something or feels a certain way can be very intimidating and implies that the client must defend his or her behavior or feelings.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 30. A client states, You wont believe what my husband said to me during visiting hours. He has no right treating me that way. Which nursing response would best assess the situation that occurred?

A. Does your husband treat you like this very often?

B. What do you think is your role in this relationship?

C. Why do you think he behaved like that?

D. Describe what happened during your time with your husband.

ANS: D This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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31. Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations?

A. My sister has the same diagnosis as you and she also hears voices.

B. I understand that the voices seem real to you, but I do not hear any voices.

C. Why not turn up the radio so that the voices are muted.

D. I wouldnt worry about these voices. The medication will make them disappear.

ANS: B This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 32. Which nursing statement is a good example of the therapeutic communication technique of offering self?

A. I think it would be great if you talked about that problem during our next group session.

B. Would you like me to accompany you to your electroconvulsive therapy treatment?

C. I notice that you are offering help to other peers in the milieu.

D. After discharge, would you like to meet me for lunch to review your outpatient progress?

ANS: B This is an example of the therapeutic communication technique of offering self. Offering self makes the nurse available on an unconditional basis, increasing clients feelings of self-worth. Professional boundaries must be maintained when using the technique of offering self.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 33. A client slammed a door on the unit several times. The nurse responds, You seem angry. The client states, Im not angry. What therapeutic communication technique has the nurse employed, and what defense mechanism is the client unconsciously demonstrating?

A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement ANS: B This is an example of the therapeutic communication technique of verbalizing the implied. The nurse is putting into words what the client has only implied by words or actions. Denial is the refusal of the client to acknowledge the existence of a real situation, the feelings associated with it, or both.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response

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34. Which of the following individuals are communicating a message? Select all that apply.

A. A mother spanking her son for playing with matches B. A teenage boy isolating himself and playing loud music C. A biker sporting an eagle tattoo on his biceps D. A teenage girl writing, No one understands me E. A father checking for new e-mail on a regular basis ANS: A, B, C, D The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to 90% of communication is nonverbal.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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Chapter 09. The Nursing Process in Psychiatric/Mental Health Nursing Multiple Choice 1. Which data-gathering technique is employed during the assessment phase of the nursing process?

A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?

A. Medical history is of little significance and can be eliminated from the nursing assessment.

B. Assessment provides a holistic view of the client, including biopsychosocial aspects.

C. Comprehensive assessments can be performed only by advanced practice nurses.

D. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 3. Which nursing diagnosis should a nurse identify as being correctly formulated?

A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy response (inference), the contributing factors, and the data that support the inference.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 4. Which expected client outcome should a nurse identify as being correctly formulated?

A. Client will feel happier by discharge.

B. Client will demonstrate two relaxation techniques.

C. Client will verbalize triggers to anger by end of session.

D. Client will initiate interaction with one peer during free time within 2 days.

ANS: D The statement Client will initiate interaction with one peer during free time within 2 days is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 5. Which statement regarding nursing interventions should a nurse identify as accurate?

A. Nursing interventions are independent from the treatment teams goals.

B. Nursing interventions are directed solely by written physician orders.

C. Nursing interventions occur independently but in concert with overall treatment team goals.

D. Nursing interventions are standardized by policies and procedures.

ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the clients care.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 6. Within the nurses scope of practice, which function is exclusive to the advance practice psychiatric nurse?

A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 7. A nurse charts Verbalizes understanding of the side effects of Prozac. This is an example of which category

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of focused charting?

A. Data B. Problem C. Action D. Response ANS: D Verbalizes understanding of the side effects of Prozac is an example of the response category of focused charting. The response is a description of the clients reaction to any part of medical or nursing care.

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment 8. The nurse should recognize which acronym as representing problem-oriented charting?

A. SOAPIE B. SOLER C. DAR D. PQRST ANS: A The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each.

KEY: Cognitive Level: Comprehension | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment 9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

A. CIWA scale B. GGT C. MMSE D. CAPS scale ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinicianadministered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 10. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

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A. Mood B. Perception C. Orientation D. Affect ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the clients orientation. Assessment of the clients orientation to reality is part of a mental status evaluation.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. What is the purpose when a nurse gathers client information?

A. It enables the nurse to modify client behaviors related to personality disorders.

B. It enables the nurse to make sound clinical judgments and plan appropriate client care.

C. It enables the nurse to prescribe the appropriate medications.

D. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical nursing judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers (consistent with HIPAA laws and the clients right to confidentiality).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 12. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 13. The following outcome was developed for a client: Client will list five personal strengths by the end of day 1. Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

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A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The selfcare deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 14. How should a nurse prioritize nursing diagnoses?

A. By the established goal of care B. By the life-threatening potential C. By the physicians priority of care D. By the clients preference ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurses first priority.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment 15. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this clients problem?

A. The client will avoid daytime napping and attend all groups.

B. The client will exercise, as needed, before bedtime.

C. The client will sleep 7 uninterrupted hours by day four of hospitalization.

D. The clients sleep habits will improve during hospitalization.

ANS: C The outcome The client will sleep 7 uninterrupted hours by day four of hospitalization is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 16. The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?

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A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism.

B. The client has a history of four suicide attempts in adolescence.

C. The client expresses hopelessness and helplessness and isolates self.

D. The client has disorganized thought processes and delusional thinking.

ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of nursing diagnosis of risk for suicide. Disorganized thoughts and delusional thinking would lead to the development of a nursing diagnosis of altered thought processes.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 17. A student nurse asks an instructor which resource is best to use when developing nursing outcomes for clients. Which reply by the instructor most accurately answers the students question?

A. Use the Nursing Interventions Classification (NIC), as a reference for nursing outcomes.

B. Use the NANDA resource to identify appropriate outcomes.

C. Use the Nursing Outcomes Classification (NOC), as a reference for nursing outcomes.

D. Copy your standard outcomes from a nursing care plan textbook.

ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions. NANDA is a resource for identifying approved nursing diagnoses.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this clients problem?

A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion ANS: B The nursing diagnosis altered sensory perception accurately reflects the clients symptoms of hearing things that others do not. A nursing diagnosis describes a clients condition and facilitates the prescription of interventions.

Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 19. A nursing instructor is teaching students about the purpose of using the nursing process in the care of psychiatric patients. Which of the following statements by the student indicates that learning has occurred?

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A. The nursing process is a method for interviewing the patient in a systematic way.

B. The nursing process is used to assist patients to adapt successfully to stressors within the environment.

C. The nursing process is used to provide support for the psychiatric diagnosis.

D. The nursing process is used primarily to minimize allegations of negligence.

ANS: B The nursing process is a method for nursing care delivery in which the patients unhealthy responses are identified and interventions are planned, which are designed to assist the patient to adapt more successfully in their environment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 20. A client is diagnosed with generalized anxiety disorder. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse?

A. Assessing the clients level of anxiety B. Assessing and documenting the clients vital signs C. Assessing suicide risk D. Assessing availability of support systems ANS: A Anxiety at a moderate or higher level will interfere with the learning process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 21. During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client?

A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 22. A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation?

A. Provide warm milk and a backrub.

B. Give a sleep medication.

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C. Hold a relaxation group before bedtime.

D. Review the clients normal sleep pattern.

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. In this situation the nurse must initially determine the clients normal sleep patterns in order to evaluate if a true problem exists.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 23. An instructor overhears a student say, That family seems to disagree more than agree. The family seems to be dysfunctional. To further assess the familys situation, which would be an appropriate instructor reply?

A. Families who disagree can be a challenge to the treatment team.

B. You seem very critical of the family. Do you believe that you are unable to help them?

C. Lets bring the family in for an educational session to improve their communication.

D. What appears to trigger family disagreements?

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 24. Which nursing response would be appropriately used in the evaluation phase of the nursing process?

A. If I were in your situation, I would not repeat a behavior that has caused problems.

B. What do you think needs changing, and what do you want to do differently?

C. What exactly will it take to carry out your plan, and what else do you need to do?

D. It sounds like youre saying this new approach is working for you.

ANS: D In the evaluation phase of the nursing process, the nurse and the client evaluate progress toward attainment of the expected outcomes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 25. A client diagnosed with major depressive disorder states, Why should I keep trying to get a job? I mess up everything I do. Which correctly written nursing diagnosis best reflects the content and mood themes in this clients statement?

A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment

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D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem; it doesnt yet exist. The clients statement indicates that role performance is altered because fear of failure prevents seeking employment.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 26. During an intake interview, which question would assist the nurse in gathering data about the clients judgment?

A. What brought you to the hospital? Do you know what day and season it is now?

B. On a scale of 1 to 10, how would you rate your stress level?

C. What does the phrase a rolling stone gathers no moss mean to you?

D. If you found a stamped, addressed envelope in the street, what would you do?

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment on the basis of the clients action choice.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 27. An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals?

A. What do you think needs to change about how you express anger?

B. How did you feel after attending the anger management session?

C. On a scale of 1 to 10, please rate your current level of anger.

D. What bothers you about the actions of others when you get angry?

ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 28. The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview?

A. Appears uncooperative. Exhibits characteristics of depression.

B. Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression.

C. States I dont need to be here when discussing admission status. Maintains minimal eye contact and offers

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little data related to triggers for admission.

D. Unwilling to respond openly during interview.

ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the clients legal record should be objective and based on assessed data. Implications and generalizations should be avoided.

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment 29. A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating, Although Id like to, I dont join in because I dont speak the language so good. Which correctly written outcome addresses this clients problem?

A. The client will collaborate with nursing staff to set specific goals by day 3.

B. The client will participate in one group activity of choice by day 2.

C. The client will express a desire to interact with others.

D. The client will become increasingly independent by discharge.

ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 30. The following clients are seen in the emergency department. The psychiatric unit has one remaining bed.

The triage nurse should expect which client to be admitted?

A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, Kill your infant son.

D. The client who argued with her boyfriend and inflicted a superficial cut on her arm ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the clients health or situation. These data are prioritized to meet client needs, with an emphasis on safety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment Multiple Response 31. Which of the following nursing interventions fall within the standards of psychiatricmental health clinical nursing practice for a nurse generalist? Select all that apply.

A. Assist clients to perform activities of daily living.

B. Act as a consultant with other clinicians to provide services for clients and effect system change

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C. Encourage clients to discuss triggers for relapse D. Use prescriptive authority in accordance with state and federal laws E. Educate families about signs and symptoms of alcohol dependence and withdrawal ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatricmental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 32. Which of the following are characteristics of accurately developed client outcomes? Select all that apply.

A. Client outcomes are formulated by nurses independent from other team members.

B. Client outcomes are not restricted by time frames.

C. Client outcomes are specific and measurable.

D. Client outcomes are realistically based on client capability.

E. Client outcomes are formally approved by the psychiatrist.

ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment.

Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 33. After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply.

A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature ANS: B, C, E A nursing diagnosis is a statement of a clients functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem; it does not yet exist.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment

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Chapter 10. Therapeutic Groups Multiple Choice 1. During a therapeutic group, a client talks about personal accomplishments in an effort to gain attention.

Which group role, assumed by this client, should the nurse identify?

A. The task role of gatekeeper B. The individual role of recognition seeker C. The maintenance role of dominator D. The task role of elaborator ANS: B The nurse should evaluate that the client is assuming the individual role of the recognition seeker. Other individual roles include the aggressor, the blocker, the dominator, the help seeker, the monopolizer, and the seducer.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 2. During a therapeutic group, two clients engage in an angry verbal exchange. The nurse leader interrupts the exchange and excuses both of the clients from the group. The nurse has demonstrated which leadership style?

A. Autocratic B. Democratic C. Laissez-faire D. Bureaucratic ANS: A The nurse who excuses clients from the group has demonstrated an autocratic leadership style. An autocratic leadership style may be useful in certain situations that require structure and limit-setting. Democratic leaders focus on the members of the group and group-selected goals. Laissez-faire leaders provide no direction to group members.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 3. During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style?

A. The nurse mandates that all group members reveal an embarrassing personal situation.

B. The nurse asks for a show of hands to determine group topic preference.

C. The nurse sits silently as the group members stray from the assigned topic.

D. The nurse shuffles through papers to determine the facility policy on length of group.

ANS: C The nurse leader who sits silently and allows group members to stray from the assigned topic is demonstrating a laissez-faire leadership style. This style allows group members to do as they please with no direction from the leader. Group members often become frustrated and confused in reaction to a laissez-faire leadership style.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 4. During a community meeting, a nurse encourages clients to present unit problems and discuss possible solutions. Which type of leadership style is the nurse demonstrating?

A. Democratic B. Autocratic C. Laissez-faire D. Bureaucratic ANS: A The nurse who encourages clients to present problems and discuss solutions is demonstrating a democratic leadership style. Democratic leaders share information with group members and promote decision making by the members of the group. The leader provides guidance and expertise as needed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. Which situation should a nurse identify as an example of an autocratic leadership style?

A. The president of Sigma Theta Tau assigns members to committees to research problems.

B. Without faculty input, the dean mandates that all course content be delivered via the Internet.

C. During a community meeting, a nurse listens as clients generate solutions.

D. The student nurses association advertises for candidates for president.

ANS: B The nurse should identify that mandating decisions without consulting the group is considered an autocratic leadership style. Autocratic leadership increases productivity but often reduces morale and motivation due to lack of member input and creativity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 6. A single, pregnant teenager in a parenting class discloses her ambivalence toward the pregnancy and the subsequent guilt that these thoughts generate. A mother of three admits to having felt that way herself. Which of Yaloms curative group factors does this illustrate?

A. Imparting of information B. Instillation of hope C. Altruism D. Universality ANS: D The scenario is an example of the curative group factor of universality. Universality occurs when individuals realize that they are not alone in the problems, thoughts, and feelings they are experiencing. This realization reduces anxiety by the support and understanding of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:

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Psychosocial Integrity 7. A man diagnosed with alcohol dependence experiences his first relapse. During his AA meeting, another group member states, I relapsed three times, but now have been sober for 15 years. Which of Yaloms curative group factors does this illustrate?

A. Imparting of information B. Instillation of hope C. Catharsis D. Universality ANS: B This scenario is an example of the curative group factor of instillation of hope. This occurs when members observe the progress of others in the group with similar problems and begin to believe that personal problems can also be resolved.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. During a group discussion, members freely interact with each other. Which member statement is an example of Yaloms curative group factor of imparting information?

A. I found a Web site explaining the different types of brain tumors and their treatment.

B. My brother also had a brain tumor and now is completely cured.

C. I understand your fear and will be by your side during this time.

D. My mother was also diagnosed with cancer of the brain.

ANS: A Yaloms curative group factor of imparting information involves sharing knowledge gained through formal instruction as well as by advice and suggestions given by other group members.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. Prayer group members at a local Baptist church are meeting with a poor, homeless family they are supporting. Which member statement is an example of Yaloms curative group factor of altruism?

A. Ill give you the name of a friend that rents inexpensive rooms.

B. The last time we helped a family, they got back on their feet and prospered.

C. I can give you all of my baby clothes for your little one.

D. I can appreciate your situation. I had to declare bankruptcy last year.

ANS: C Yaloms curative group factor of altruism occurs when group members provide assistance and support to each other, creating a positive self-image and promoting self-growth. Individuals increase self-esteem through mutual caring and concern.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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10. During an inpatient educational group, a client shouts out, This information is worthless. Nothing you have said can help me. These statements indicate to the nurse leader that the client is assuming which group role?

A. The group role of aggressor B. The group role of initiator C. The group role of gatekeeper D. The group role of blocker ANS: A The nurse should identify that the client is assuming the group role of the aggressor. The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 11. A nurse believes that the members of a parenting group are in the initial, or orientation, phase of group development. Which group behaviors would support this assumption?

A. The group members manage conflict within the group.

B. The group members use denial as part of the grief response.

C. The group members compliment the leader and compete for the role of recorder.

D. The group members initially trust one another and the leader.

ANS: C The nurse should anticipate that members in the initial, or orientation, phase of group development often compliment the leader and compete for the role of recorder. Members in this phase have not yet established trust and have a fear of not being accepted. Power struggles may occur as members compete for their position in the group.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 12. During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?

A. Its hard for me to tell my story when Im not sure about the reactions of others.

B. I think Joes Antabuse suggestion is a good one and might work for me.

C. My situation is very complex, and I need professional, not peer, advice.

D. I am really upset that you expect me to solve my own problems.

ANS: B The nurse should determine that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and then use it constructively to foster change.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

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13. Which group leader activity should a nurse identify as being most important in the final, or termination, phase of group development?

A. The group leader establishes the rules that will govern the group after discharge.

B. The group leader encourages members to rely on each other for problem solving.

C. The group leader presents and discusses the concept of group termination.

D. The group leader helps the members to process feelings of loss.

ANS: D The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. A nursing instructor is teaching students about self-help groups like Alcoholics Anonymous (AA). Which student statement indicates that learning has occurred?

A. There is little research to support AAs effectiveness.

B. Self-help groups used to be the treatment of choice, but their popularity is waning.

C. These groups have no external regulation, so clients need to be cautious.

D. Members themselves run the group, with leadership usually rotating among the members.

ANS: D The student indicates an understanding of self-help groups when stating, Members themselves run the group, with leadership usually rotating among the members. Nurses may or may not be involved in self-help groups.

These groups allow members to talk about feelings and reduce feelings of isolation, while receiving support from others undergoing similar experiences.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 15. The nurse should utilize which group function to help an extremely withdrawn, paranoid client increase feelings of security?

A. Socialization B. Support C. Empowerment D. Governance ANS: B The nurse should identify that the group function of support would help an extremely withdrawn, paranoid client increase feelings of security. Support assists group members in gaining a feeling of security from group involvement.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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16. When planning group therapy, a nurse should identify which configuration as most optimal for a therapeutic group?

A. Open-ended membership; circle of chairs; group size of 5 to 10 members B. Open-ended membership; chairs around a table; group size of 10 to 15 members C. Closed membership; circle of chairs; group size of 5 to 10 members D. Closed membership; chairs around a table; group size of 10 to 15 members ANS: C The nurse should identify that the most optimal conditions for a therapeutic group are when the membership is closed and the group size is between 5 and 10 members who are arranged in a circle of chairs. The focus of therapeutic groups is on relationships within the group and the interactions among group members.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment: Management of Care 17. During the sixth week of a 10-week parenting skills group, a nurse observes as several members get into a heated dispute about spanking. As a group, they decide to create a pros-and-cons poster on the use of physical discipline. At this time, what is the role of the group leader?

A. To referee the debate B. To adamantly oppose physical discipline measures C. To redirect the group to a less controversial topic D. To encourage the group to solve the problem collectively ANS: D The role of the group leader is to encourage the group to solve the problem collectively. A democratic leadership style supports members in their participation and problem-solving. Members are encouraged to cooperatively solve issues that relate to the group.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 18. A 10-week, prenuptial counseling group composed of five couples is terminating. At the last group meeting, a nurse notices that the two most faithful and participative couples are absent. When considering concepts of group development, what might explain this behavior?

A. They are experiencing problems with termination, leading to feelings of abandonment.

B. They did not think any new material would be covered at the last session.

C. They were angry with the leader for not extending the length of the group.

D. They were bored with the material covered in the group.

ANS: A The nurse should determine that the clients absence from the final group meeting may indicate that they are experiencing problems with termination. The termination phase of group development may elicit feelings of abandonment and anger. Successful termination may help members develop skills to cope with future unrelated losses.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:

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Psychosocial Integrity 19. An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Without further education, which group is this nurse most qualified to lead?

A. A psychodrama group B. A psychotherapy group C. A parenting group D. A family therapy group ANS: C A psychiatric registered nurse is qualified to lead a parenting group. A parenting group can be classified as either a teaching group or therapeutic group. Psychodrama, psychotherapy, and family therapy are forms of group therapy that must be facilitated by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 20. A nursing instructor is teaching about psychodrama, a specialized type of therapeutic group. Which student statement indicates that further teaching is necessary?

A. Psychodrama provides a safe setting in which to discuss painful issues.

B. In psychodrama, the client is the protagonist.

C. In psychodrama, the client observes actor interactions from the audience.

D. Psychodrama facilitates resolution of interpersonal conflicts.

ANS: C The nurse should educate the student that in psychodrama the client plays the role of himself or herself in a life-situation scenario and is called the protagonist. During psychodrama, the client does not observe interactions from the audience. Other group members perform the role of the audience and discuss the situation they have observed, offer feedback, and express their feelings. Leaders of psychodrama must have specialized training to become a psychodramatist.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity Multiple Response 21. Which of the following observed client behaviors would lead a nurse to evaluate a member as assuming a maintenance group role? Select all that apply.

A. A client decreases conflict within the group by encouraging compromise.

B. A client offers recognition and acceptance of others.

C. A client outlines the task at hand and proposes solutions.

D. A client listens attentively to group interaction.

E. A client uses the group to gain sympathy from others.

ANS: A, B, D

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The nurse should identify clients who decrease conflict within the group, offer recognition and acceptance of others, and listen attentively to group interaction as assuming a maintenance group role. There are member roles within each group. Maintenance roles include the compromiser, the encourager, the follower, the gatekeeper, and the harmonizer.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 22. Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? Select all that apply.

A. Encouraging members to provide feedback to each other about individual progress B. Ensuring that rules established by the group do not interfere with goal fulfillment C. Working with group members to establish rules that will govern the group D. Emphasizing the need for and importance of confidentiality within the group E. Helping the members to resolve conflicts and foster cohesiveness within the group ANS: B, C, D During the orientation phase of group development, the nurse leader should work together with members to establish rules that will effectively govern the group. The leader should ensure that group rules do not interfere with goal fulfillment and establish the need for and importance of confidentiality within the group. Members need to establish trust and cohesion to move into the working phase of group development.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

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Chapter 11. Intervention With Families Multiple Choice 1. A fatherless, 11-year-old African American girl lives with her grandmother after the death of her mother.

Her older stepbrother is very involved in her life. How should the community health nurse view this family constellation, and why?

A. Abnormal; the grandmother should be concerned with issues other than childrearing.

B. Abnormal; a two-parent household is the most advantageous arrangement for parenting.

C. Normal; cultural variations exist in the family life cycle.

D. Normal; because of their wisdom, older adults make better parenting figures.

ANS: C The nurse should be aware that cultural differences and specific events may lead to variety in family constellations. This is normal.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. In defiance of parental wishes, a Japanese teenager succumbs to peer pressure and gets a tattoo. According to Bowens family systems theory, how should the community health nurse interpret the teenagers action?

A. The teenager is attempting to differentiate self.

B. The teenager is triangulating self.

C. The teenager is cutting self off emotionally.

D. The teenager is exhibiting antisocial traits.

ANS: A The teenager is taking on some of the cultural values of peers and is beginning to develop a unique identity.

This process is called differentiation and is a normal task of adolescence.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 3. A home health nurse is visiting an Asian family. A married couple, their three children, and the maternal grandparents all live in the home. How should the nurse interpret the presence of the grandparents in the home?

A. The parents have diffuse boundaries and have allowed the grandparental subsystem to be present.

B. The grandparental subsystem is not successfully managing separation from the parental subsystem.

C. Extended family living arrangements are common in some cultures.

D. The nuclear family living arrangement is the preferred environment for childrearing.

ANS: C The Asian culture highly respects the elderly. Having the grandparents living in the home is not uncommon in this culture.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

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4. A depressed 21-year-old client has lived with his mother ever since the death of his father 3 years ago. After the client received a college acceptance, the mother repeatedly states, Thats wonderful. Ill be fine all alone.

How would the nurse interpret the mothers statements?

A. The mother is withholding supportive messages.

B. The mother is expressing denigrating remarks.

C. The mother is communicating indirectly.

D. The mother is using double-bind communication.

ANS: D The clients mother says she is fine with him going away to college but then tries to make him feel guilty about her being left alone. The client is in a no-win situation because his mother has given a mixed messagea doublebind communication.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity 5. In a family that is in the life cycle stage called The Family with Adolescents, which changes must occur for the family to proceed developmentally?

A. Making adjustments within the marital system to meet the responsibilities of parenthood B. Establishing a new identity as a couple by realigning relationships with extended family C. Redefining the level of dependence so that adolescents are provided with greater autonomy D. Reestablishing the bond of the dyadic marital relationship ANS: C Stage IV of the family life cycle is described as The Family with Adolescents. The task of this stage is to redefine the level of dependence so that adolescents are provided with greater autonomy while parents remain responsive to teenagers dependency needs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. A clinic nurse is caring for a 40-year-old client who lives with his parents. The clients mother continues to do the clients laundry and provides spending money. Based on this situation, which family dynamic does the nurse recognize?

A. Taking over B. Communicating indirectly C. Belittling feelings D. Making assumptions ANS: A Taking over occurs when a family member fails to allow another member to develop a sense of responsibility and self-worth. By doing the clients laundry and managing finances, the mother is fostering the clients dependence.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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7. A 30-year-old client seeking therapy states, My mom cries when she is not included in all my social activities and thinks of my friends as her own. How would the nurse describe the boundaries between this familys parent and child subsystems?

A. The boundaries are rigid.

B. The boundaries are restructured.

C. The boundaries are enmeshed.

D. The boundaries are disengaged.

ANS: C With enmeshed boundaries, family members lack individuation and experience exaggerated connectedness.

The clients mother is trying to prevent independence by generating feelings of guilt.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity 8. A nurse enters an inpatient room and finds the family disagreeing about the clients living arrangements after discharge. Which information should the nurse provide when teaching techniques to resolve family conflicts?

A. All family members should use past incidents to make their point.

B. One family member should act as a gatekeeper in order to avoid family confrontation.

C. One family member should act as a compromiser to preserve harmony in the family system.

D. All family members should respect differing opinions and use compromise and negotiation.

ANS: D Functional families allow and respect differences among members. They learn to handle differences and conflict through negotiation and compromise.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance 9. After hearing parents discuss divorce, a 5-year-old develops behavioral problems. Upon dealing with the childs behavioral issues, the marital relationship conflict decreases. The pediatric clinic nurse should recognize that this is an example of which family system concept?

A. Differentiation of self B. Triangulation C. Fusion D. Emotional cutoff ANS: B Triangulation occurs when a relationship between two people is dysfunctional so a third person is brought into the relationship to help stabilize it. The son and his behavioral problems redirect the focus from the couples marital problems.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 10. An instructor is teaching about differentiated parent and adult child relationships. Students are instructed to

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give an example of a well-differentiated parent and adult child relationship. Which student example meets the instructor requirement?

A. An adult child considers, but is not governed by, the advice of his or her parents.

B. An adult child appears to listen, but ignores, the advice of his or her parents.

C. An adult child respects and is governed by the wishes of his or her parents.

D. An adult child never requests advice or feedback from his or her parents.

ANS: A The correct student example of a well-differentiated parent and adult child relationship is when an adult child considers, but is not governed by, the advice of his or her parent. The adult child should be differentiated enough not to be threatened by parental advice and should be able to consider the parental advice without feeling the advice must be followed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. During family counseling a husband states, Every time my wife and I discuss child discipline, we get into shouting matches. The nurse instructs the couple to shout at each other for 2 weeks on Tuesdays and Thursdays for 30 minutes. What intervention is the nurse using?

A. Reframing B. Restructuring the family C. Expressive psychotherapy D. Paradoxical intervention ANS: D In a paradoxical intervention, the therapist requests the family to continue the maladaptive behavior. This removes control over the behavior from the family to the therapist. Clients are made more aware of the defeating behavior and this can lead to behavioral change.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. During family counseling a child states, I just want to surf like other kids. Mom says its okay, but Dad says Im too young. The mother allows surfing when the father is absent. In the structural model of family therapy, what family interactional pattern should the nurse recognize?

A. Multigenerational transmission B. Disengagement C. Motherchild subsystem D. Emotional cutoff ANS: C In this situation the mother and child have formed a subsystem in which they have aligned themselves against the father.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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13. During family counseling, a husband tells his wife to spend more time with the family, and she responds by stating, Okay, Ill turn in my resignation tomorrow. The husband replies, I knew it! Youve always been a quitter! How should the nurse interpret the husbands statement?

A. The husband is expressing an emotional cutoff.

B. The husband is expressing double-bind communication.

C. The husband is expressing indirect messages.

D. The husband is expressing avoidance behaviors.

ANS: B Double-bind communication sets up no-win situations. The husband has created a situation in which no matter what the wife does, she is wrong.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. A couple has been married for 20 years. They argue constantly, belittle feelings, and continuously contradict each other. During a therapy session, the nurse documents Marital schism. What does the nurse mean by this documentation?

A. The couple has a compatible marriage relationship.

B. The husband has a dominant relationship over the wife.

C. The couple has an enmeshed relationship.

D. The couple has an incompatible marriage relationship.

ANS: D A marital schism is a state of chronic disequilibrium and discord. This describes this couples marriage.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. A couple is in counseling related to their dysfunctional relationship. Their daughter has recently made a suicide gesture. The nurse should recognize that this might be an example of which family system concept?

A. Triangulation B. Pseudohostility C. Double-bind communication D. Pseudomutuality ANS: A Triangulation occurs when a relationship between two people is dysfunctional. A third person is brought into the relationship to help stabilize it. The couple is triangulating with their daughter. The threatened daughter draws attention from her parents interpersonal conflicts by her own dysfunctional behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 16. An adolescent, his mother, and his soon-to-be stepfather have been in counseling with the nurse. Which statement by the nurse fosters positive relationships within this new family structure?

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A. Stepchildren should be consistently disciplined by only one parent.

B. It is most important to give your full attention to the childs adjustment since it is most difficult for them.

C. Keeping the lines of communication open between everyone in the family is important in establishing healthy relationships.

D. Children need to decide who will be their disciplinarian because this new situation will be stressful.

ANS: C Open lines of communication are needed for newly forming families to begin their relationship together and establish a new family structure.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. A nursing instructor is teaching about the importance of healthy family-member expectations for newly blended families. Which student statement indicates a need for further instruction?

A. Healthy family-member expectations should be flexible.

B. Healthy family-member expectations should be conforming.

C. Healthy family-member expectations should be individual.

D. Healthy family-member expectations should be realistic.

ANS: B Conforming is a behavior that interferes with adaptive functioning in terms of family member expectations.

This student statement indicates a need for further instruction. Realism, flexibility, and individuality are all characteristics of healthy family-member expectations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 18. A client is angry because her husband has forgotten their anniversary. The following week, the client is still unwilling to discuss this with her husband because she is afraid she will lose control. How should the nurse interpret this clients means of coping with anger?

A. Coping by attacking B. Coping by surrendering C. Coping by avoiding D. Coping by belittling ANS: C When coping by avoidance, differences are never acknowledged openly. The individual who disagrees avoids discussing it for fear that the other person will withdraw love or approval or become angry in response to the disagreement. Avoidance also occurs when an individual fears loss of control of his or her temper.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

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Chapter 12. Milieu Therapy - The Therapeutic Community Multiple Choice 1. An angry client on an inpatient unit approaches a nurse, stating, Someone took my lunch! People need to respect others, and you need to do something about this now! The nurses response should be guided by which basic assumption of milieu therapy?

A. Conflict should be avoided at all costs on inpatient psychiatric units.

B. Conflict should be resolved by the nursing staff.

C. Every interaction is an opportunity for therapeutic intervention.

D. Conflict resolution should be addressed only during group therapy.

ANS: C The nurses response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. A client on an inpatient unit angrily states to a nurse, Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

A. Ill talk to Peter and present your concerns.

B. Why are you overreacting to this issue?

C. You should bring this to the attention of your treatment team.

D. I can see that you are angry. Lets discuss ways to approach Peter with your concerns.

ANS: D The most appropriate nursing response involves restating the clients feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A newly admitted client asks, Why do we need a unit schedule? Im not going to these groups. Im here to get some rest. Which is the most appropriate nursing reply?

A. Group therapy provides the opportunity to learn and practice new coping skills.

B. Group therapy is mandatory. All clients must attend.

C. Group therapy is optional. You can go if you find the topic helpful and interesting.

D. Group therapy is an economical way of providing therapy to many clients concurrently.

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 4. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment?

A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 5. To promote self-reliance, how should a psychiatric nurse best conduct medication administration?

A. Encourage clients to request their medications at the appropriate times.

B. Refuse to administer medications unless clients request them at the appropriate times.

C. Allow the clients to determine appropriate medication times.

D. Take medications to the clients bedside at the appropriate times.

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic?

A. Dream analysis B. Creative cooking C. Paint by number D. Stress management ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a clients learning readiness. Other topics for education groups include medical diagnoses, side effects

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of medications, and the importance of medication compliance.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 7. What is the best rationale for including the clients family in therapy within the inpatient milieu?

A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors ANS: B The nurse should include the clients family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. How does a democratic form of self-government in the milieu contribute to client therapy?

A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 9. A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results?

A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client.

Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 10. In the role of milieu manager, which activity should the nurse prioritize?

A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the clients safety and physiological needs are met within the milieu.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity Multiple Response 11. A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? Select all that apply.

A. Respiratory therapist B. Occupational therapist C. Recreational therapist D. Social worker E. Mental health technician ANS: B, C, D, E The typical interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, dietician, psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. Other disciplines may be included on the basis of resources available in a particular hospital setting and individual patient needs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 12. Which of the following are accurate descriptors of a therapeutic community? Select all that apply.

A. The unit schedule includes unlimited free time for personal reflection.

B. Unit responsibilities are assigned according to client capabilities.

C. A flexible schedule is determined by client needs.

D. The individual is the sole focus of therapy.

E. A democratic form of government exists.

ANS: B, E

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In a therapeutic community the unit responsibilities are assigned according to client capability, and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

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Chapter 13. Crisis Intervention Multiple Choice 1. A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis?

A. This type of crisis is precipitated by unexpected external stressors.

B. This type of crisis is precipitated by preexisting psychopathology.

C. This type of crisis is precipitated by an acute response to an external situational stressor.

D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

ANS: D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, I cant function any longer under all this stress. Which type of crisis is the client experiencing?

A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis ANS: B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity 3. A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this clients crisis?

A. The client will change his or her type A personality traits to more adaptive ones by week 1.

B. The client will list five positive self-attributes.

C. The client will examine how childhood events led to an overachieving orientation.

D. The client will return to previous adaptive levels of functioning by week 6.

ANS: D The nurse should identify that a realistic long-term outcome for this client would be to return to previous

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adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client?

A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations ANS: C The priority nursing diagnosis for this client is Risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 5. After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?

A. Are you currently thinking about harming yourself?

B. Why do you want to harm yourself?

C. Have you thought about the consequences of your actions?

D. Who is your emergency contact person?

ANS: A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor.

Which intervention should a nurse prioritize to address this behavior?

A. Initiate forced medication protocol.

B. Help the client to explore the source of anger.

C. Ignore the act to avoid reinforcing the behavior.

D. With staff support and a show of solidarity, set firm limits on the behavior.

ANS: D

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The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?

A. Youve really been helpful. Can I count on you for continued support?

B. I dont work out anymore.

C. Im really glad I didnt go home. It would have been hard to come back.

D. I carry mace when I jog. It makes me feel safe and secure.

ANS: D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 8. A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate?

A. Im confident you know whats best for you.

B. This may not be the best time for you to make such an important decision.

C. Your children will be terribly disappointed.

D. Tell me why you want to make this change.

ANS: B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 9. An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression?

A. The client requests prn medications.

B. The client has a tense facial expression and body language.

C. The client refuses to eat lunch.

D. The client sits in group therapy with back to peers.

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ANS: B The nurse should assess that tense facial expressions and body language may indicate that a clients anger is escalating. The nurse should conduct a thorough assessment of the clients past and current violent behaviors and develop interventions for de-escalation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst?

A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger ANS: C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst is to process feelings and concerns related to the witnessed intervention.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 11. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply.

A. Tell me what happened.

B. What coping methods have you used, and did they work?

C. Describe to me what your life was like before this happened.

D. Lets focus on the current problem.

E. Ill assist you in selecting functional coping strategies.

ANS: A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply.

A. Maintain a calm demeanor.

B. Clearly delineate the consequences of the behavior.

C. Use therapeutic touch to convey empathy.

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D. Set limits on the behavior.

E. Teach the client to avoid I statements related to expression of feelings.

ANS: A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the clients anger.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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Chapter 14. Assertiveness Training Multiple Choice 1. During a psychoeducational group on assertiveness training, a client asks, Why do we need to learn about this stuff? Which is the most appropriate nursing reply?

A. Because your doctor requires you to attend this group.

B. Being assertive is the ability to stand up for yourself while respecting the rights of others.

C. Assertiveness training teaches you how to ask for what you want, when you want it.

D. Assertive people place the needs and rights of others before their own.

ANS: B Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. Two clients are roommates on an inpatient psychiatric unit. At breakfast, client A, who had been missing her gold locket, notices client B wearing it. Which should a nurse recognize as a nonassertive or passive behavioral response from client A? A. Client A ignores the situation.

B. Client A discusses the situation with her nurse and develops a plan of action.

C. Client A immediately approaches client B and pulls the necklace off her neck.

D. Client A offers to wash client Bs clothes and accidentally spills bleach in the water.

ANS: A By ignoring the situation, client A avoids conflict, denies her feelings, and does not assertively resolve the problem. This is an example of nonassertive behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction?

A. Client is displaying assertive behaviors.

B. Client is displaying aggressive behaviors.

C. Client is displaying passive behaviors.

D. Client is displaying passiveaggressive behaviors.

ANS: D This response is passiveaggressive. The clients anger is expressed indirectly by spitting in the soup when the peer is not looking.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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4. A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, When I have to wait for more than an hour to be seen, I feel like my time is not important. The nurse recognizes this as what type of behavior?

A. Aggressive behavior B. Assertive behavior C. Passiveaggressive behavior D. Passive behavior ANS: B This response is assertive. The client is openly expressing feelings and attempting to correct a stressful situation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply?

A. Several techniques, including meditation and progressive muscle relaxation, appear helpful.

B. Theres not much that can be done about aggressive behavior because of biological responses.

C. Certain types of medications have been proven effective in promoting assertive communication.

D. There are several techniques, including I statements, role playing, and thought stopping, that can help promote assertive behaviors and decrease aggressive behaviors.

ANS: D These techniques promote assertive behaviors and would help diminish aggressive responses.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. During an assertiveness training group, a nurse suggests using I statements. The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate?

A. When I statements are used, opinions are communicated without blaming others.

B. When I statements are used, anger is displaced by using indirect means.

C. When I statements are used, responsibility for ones behavior is attributed to another.

D. When I statements are used, eye contact is promoted.

ANS: A I statements clearly state ones feelings and needs without blaming or demeaning others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an I statement. Which of the following statements is the best example of this assertive communication technique?

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A. I would like to know why you came home late without calling me.

B. I hate it when you think you can just come home late without calling anyone to let them know where you are.

C. I feel angry when you come home late without calling.

D. I think you dont care about me, because if you did, youd call me if you were planning on coming home late.

ANS: C This response clearly states feelings about a situation without blaming another.

KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Psychosocial Integrity 8. After vying for a nurse management position, nurse A is chosen over nurse B. When nurse manager A calls for staff meetings, nurse B is chronically late or absent. Nurse B is exhibiting which type of behavior?

A. Passive B. Assertive C. Aggressive D. Passiveaggressive ANS: D This response is passiveaggressive. The colleague is expressing anger indirectly by being late or absent from the meetings.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness?

A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication ANS: C Defensive coping reflects a self-protective pattern that defends against underlying perceived threats to positive self-regard. Clients who are utilizing defensive coping lack assertiveness skills.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 10. Two clients get into a heated argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, after which they will discuss and attempt to resolve the problem. The nurses action is promoting which assertive technique?

A. Defusing B. Clouding or fogging

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C. Responding as a broken record D. Shifting from content to process ANS: A Defusing is a technique that delays further discussion with an angry individual until a calm demeanor has been achieved. In the situation presented, the nurse is allowing the clients to calm down prior to addressing their issues.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which represents a passiveaggressive statement by the emergency department nurse?

A. Get someone else to work 3 to 11! Ive been working 10 days straight, and I need a break!

B. Okay. Ill do it, then purposefully leaves paperwork undone when leaving the unit at 11 p.m.

C. I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me.

D. Yes, Ill do it. Anything to keep peace with the hospital administration is a good thing.

ANS: B This response is passiveaggressive. The staff nurses anger is expressed indirectly.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. Which best describes a nurses use of assertive behavior?

A. When a nurse attempts to please others and apologizes for awkwardness in a new role B. When a nurse becomes defensive and angry when peers offer suggestions for improvement C. When a nurse has problems making decisions and has a tendency to procrastinate D. When a nurse is open and direct when asked by the nurse manager to complete assignments ANS: D This is an assertive response. There is clear expression of needs and feelings.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 13. Which is the most appropriate nursing reply when a client asks what the goal and benefit are of assertive skills training?

A. It protects the client from others who express aggressive feelings.

B. It gives reliable, expert information so that clients may correct faulty behaviors.

C. It clarifies misperceptions that have caused clients to distort reality.

D. It improves communication skills in order to improve interpersonal relationships.

ANS: D Assertiveness training helps to develop satisfying interpersonal relationships by teaching people how to

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communicate in a manner to meet their own needs while respecting the rights and needs of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance 14. An instructor is teaching about assertive rights. Which student statement indicates a need for further instruction?

A. The right to be treated with respect is an assertive right.

B. The right to say no without feeling guilty is an assertive right.

C. The right to change your mind is an assertive right.

D. The right to always put oneself first is an assertive right.

ANS: D This is not an assertive right. An assertive right is to consider others as well as yourself. This student statement indicates a need for further instruction.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 15. One nurse confronts another and says, You are always so talkative in the meetings. I dont know why you cant stay quiet sometimes. Which reply by the other nurse reflects the technique of clouding/fogging?

A. Youre right. I do speak up a lot.

B. Sounds to me like youre agitated and we need to talk. What are you truly angry about?

C. Are you offended that I speak up, or because my thoughts are in opposition to yours?

D. I have the right to express my opinion.

ANS: A This response reflects the use of clouding/fogging. When clouding/fogging is used it concurs with the critics argument without becoming defensive and without agreeing to change.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 16. A teenager gets a C in algebra. The mother angrily states, All you ever do is listen to music and text your friends. The teenager replies, What is it that youre really upset about, mom? Which response pattern is the teenager expressing?

A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for ones own statements ANS: B This response reflects the use of shifting from content to process. The teenager is changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:

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Psychosocial Integrity 17. The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, Are you upset because I believe in academic freedom or because you dont? The faculty member is using which technique to promote assertive behavior?

A. Standing up for ones basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with irony ANS: C This response reflects the use of inquiring assertively. Inquiring assertively is an attempt to seek additional information about critical statements.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 18. An aggressive nurse manager tells a staff nurse she has no business rallying staff to change the schedule.

What would be an example of a technique that the staff nurse could use to stand up for her basic human rights?

A. What is the real reason that you dont want the schedule changed?

B. Sounds to me like youre threatened by this change.

C. Are you upset because you dont want to redo the schedule?

D. I have the right to express my opinion about the schedule.

ANS: D This response reflects the use of standing up for ones basic human rights.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly states, I worked last Christmas and will not work this Christmas.

When the supervisor says But I need you to work, the nurse repeats I worked last Christmas and will not work this Christmas. This is an example of which assertive behavior technique?

A. Shifting from content to process B. Standing up for ones basic rights C. Responding as a broken record D. Defusing ANS: C Responding as a broken record is an assertive behavior technique that consists of persistently repeating in a calm voice what is wanted.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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20. A nurse has identified the following nursing diagnosis: ineffective communication R/T lack of assertiveness skills AEB inability to state needs. Which statement encourages the client to acknowledge the priority of this problem?

A. Are you having thoughts of harming yourself or others?

B. With whom are you least assertive?

C. On a scale of 1 to 10, rank the importance of being assertive.

D. When are you available to attend the assertiveness training class?

ANS: C This nursing statement encourages the client to objectively evaluate the priority of being assertive. It is important in patient-centered care for the client to prioritize his or her goals for treatment.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 21. Which of the following are behavioral components of assertive communication?

A. Listening B. You statements C. Closed posture D. Continuous direct eye contact ANS: A One part of assertiveness communication and behavior is to listen and take time to understand what is being said before giving a response.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 22. A client is experiencing high stress. The client states, My boss treats me like a doormat and thinks nothing of demanding frequent overtime. Which nursing intervention would be appropriate?

A. To incorporate the family support system into the clients plan of care B. To teach thought-reframing techniques C. To encourage the client to seek other employment D. To teach the client how to use I statements ANS: D The ability to use I statements is essential in assertive communication. The situation presented indicates that the client needs assertiveness training.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 23. A nurse is caring for four clients. Which of the following clients should the nurse identify as likely to experience difficulty in being assertive? Select all that apply.

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A. A 20-year-old woman who is completing college homework assignments for several peers.

B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder ANS: A, B, C The woman who is taking on the work of others in addition to her own may be having difficulty assertively saying no; the widow who is socially isolated may lack the necessary skills to communicate her needs; and the boy with a conduct disorder is likely to demonstrate aggressive behaviors. The business executive and an individual diagnosed with narcissistic personality disorder are the least likely to have difficulty being assertive.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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Chapter 15. Promoting Self-Esteem Multiple Choice 1. A nurse is working in a nursing home. How best can this nurse foster self-esteem in the residents of this facility?

A. Allowing them to remain in their rooms as much as they desire to maintain privacy B. Administering anti-anxiety medications as ordered C. Providing a sense of mastery over their environment by giving choices when appropriate D. Teaching assertiveness skills and self-esteem principles ANS: C A sense of having some power and control over ones life enhances self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. A client shows a nurse a piece of artwork that took 3 days to create. How will this achievement improve the clients self-esteem?

A. By providing a framework for assertive behavior B. By providing an expression of feelings and a sense of competence and pride C. By providing a positive perception of body image D. By providing appropriate boundaries for relationship establishment ANS: B Creating the artwork provides expression of feelings and a sense of competence and pride. This will most likely have a positive effect on the clients self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. A nurse is running a group on self-esteem. A client asks, Where does self-esteem come from? Which is the most appropriate nursing reply?

A. Many factors, over the life span, influence development and maintenance of self-esteem.

B. Self-esteem is determined by factors outside of an individuals control.

C. Self-esteem is established in childhood and remains relatively fixed throughout life.

D. Genetics are the single largest contributor to an individuals self-esteem.

ANS: A Self-esteem refers to the degree of regard or respect that individuals have for themselves and is a measure of worth that they place on their abilities and judgments. Many factors influence the development of self-esteem over a persons life span.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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4. In what way should a nurse expect a school-aged child to gain positive self-esteem, according to Eriksons psychosocial developmental stages?

A. Through basic need fulfillment and environmental predictability B. Through exploration and experimentation, resulting in self-confidence in ability to perform C. Through positive reinforcement of creativity and recognition of performance D. Through receiving recognition when learning, competing, and performing successfully ANS: D The school-aged child develops self-confidence by learning, competing, and performing successfully and receiving recognition from significant others, peers, and acquaintances.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. The nurse is working with a 15-year-old client suffering from low self-esteem. According to Eriksons psychosocial developmental theory, which factor has most probably influenced this clients self-esteem?

A. Regret over life choices B. Lack of personal concern for others C. Inconsistent, overly harsh, or absent parental discipline D. Parental labeling of the child as good regardless of their behavior.

ANS: C When there is inconsistent, overly harsh, or absent discipline in the home, it is difficult for a teenager to develop the independent sense of self needed to achieve a positive self-esteem.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. On the basis of Eriksons theory, how should a nurse encourage a 40-year-old client to improve his or her self-esteem?

A. Encourage the client to review life goals and accomplishments.

B. Encourage the client to volunteer at a school, reading to underprivileged children.

C. Encourage the client to form lasting intimate relationships.

D. Encourage the client to seek recognition for task achievement.

ANS: B Making meaningful contributions to others is a way to meet the developmental task of the generativity versus stagnation (30 to 65 years) stage of Eriksons developmental theory. This action would promote a 40-year-old clients self-esteem.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. Which is an appropriate initial nursing intervention for a client with chronic low self-esteem?

A. Assessing the content of negative self-talk

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B. Administering anxiolytic medications C. Using reassurance and physical touch D. Using distraction techniques ANS: A Self-negating verbalizations and internal self-talk undermine self-esteem. Assessing and then intervening to limit or eliminate these negative communications will help improve self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A 30-year-old client diagnosed with depression has been exclusively cared for and financially subsidized by his mother since age 17. According to Eriksons theory, the nurse recognizes that the client has been unsuccessful in meeting which developmental task?

A. Trust B. Initiative C. Intimacy D. Ego integrity ANS: C The clients relationship with his mother has contributed to failing completion of the developmental task of intimacy in Eriksons stage of intimacy versus isolation (20 to 30 years). This has resulted in behaviors such as withdrawal, social isolation, aloneness, and the inability to form lasting relationships, leading to his diagnosis of depression.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 9. A 40-year-old female client has never experienced an intimate relationship. A nursing student tells an instructor that this client remains in Eriksons developmental stage of intimacy versus isolation. What is the instructors most appropriate reply?

A. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age.

B. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age.

C. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age.

D. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age.

ANS: A Eriksons stages of development are assessed by chronological age, not task achievement. This client is in Eriksons stage of generativity versus stagnation because she is 40 years old. The student has failed to recognize that even though the client did not successfully achieve the intimacy task of the intimacy versus isolation stage, the client must now be assessed at the age-appropriate developmental stage of generativity versus stagnation.

KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

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10. A home health nurse visits an 18-year-old client who lives with his mother. The client has been assessed as having low self-esteem. The nurse refers the client for individual counseling. During the next home visit, which assessed client behavior clearly indicates treatment success?

A. The client wants to buy a dog but has not yet asked his mothers permission.

B. The client asks his mother for permission to buy a dog.

C. The client tells his mother he plans to buy a dog.

D. The client buys a dog and hides it in the garage.

ANS: C When the client tells his mother he plans to buy a dog, he is making decisions and taking on responsibilities.

This indicates an increase in self-confidence and therefore self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 11. A 40-year-old client lives with her parents. She has a high school diploma and works at a low-paying job.

Her parents give her a weekly allowance to supplement her income. How should the nurse classify their clientparent boundaries?

A. As loose B. As rigid C. As flexible D. As enmeshed ANS: D The client and her parents are overly dependent. The parents control too many aspects of the clients life. Their boundaries are blurred so that it is hard for the client to differentiate her wants and needs from those of her parents. The clientparent boundaries are enmeshed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. A father tells his 5-year-old, Son, today instead of picking flowers in the outfield, lets try to catch a ball.

The child subsequently pays attention and catches a ball. Which principle of building self-esteem has the father implemented?

A. A sense of competence B. Unconditional love C. Realistic goals D. Reality orientation ANS: C Low self-esteem can be the result of not being able to achieve established goals. The father has set for the child a realistic goal that the child accomplished. This should promote self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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13. A nursing instructor is teaching about self-concept. Which student statement indicates a need for further instruction?

A. Self-concept is the thinking component of the self.

B. Self-concept is a system of learned beliefs about self.

C. Self-concept is the degree of regard that individuals have for themselves.

D. Self-concept is the attitudes and opinions held true about personal existence.

ANS: C Self-esteem, not self-concept, is the degree of regard that individuals have for themselves. This student statement indicates a need for further teaching.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 14. A client has continual problematic relationships and rejects others before possibly being rejected. The client states, I am afraid of failing in my job responsibilities. Which correctly written nursing diagnosis should be prioritized for this client?

A. Poor self-esteem R/T negative self-image AEB fear of failure B. Altered thought processes R/T anxiety AEB delusions C. Role confusion R/T rejection and poor job productivity D. High risk for violence: self-directed R/T rejection of others ANS: A Individuals with low self-esteem perceive themselves to be incompetent, unlovable, insecure, and unworthy. A correctly written actual nursing diagnosis must have a related to (R/T) and an evidenced by (AEB) statement.

A risk for nursing diagnosis does not contain an AEB statement because the problem has not yet occurred.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity Multiple Response 15. A nurse is caring for a client who has recently undergone a radical prostatectomy. Which of the following should the nurse recognize as objective symptoms of low self-esteem? Select all that apply.

A. Withdrawal from activities B. A decrease in self-care behaviors C. Poor eye contact D. Reports of pain E. Poor posture ANS: A, B, C, E Withdrawal from activities, a decrease in self-care behaviors, eye contact, and poor posture are all common objective manifestations of low self-esteem. A report of pain should be evaluated as a physical issue before being attributed solely to low self esteem.

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KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 16. A 47-year-old mother of two has recently undergone a radical mastectomy. She refuses to see anyone and remains isolated and withdrawn. Which of the following may be relevant nursing diagnoses for this client?

Select all that apply.

A. Disturbed body image B. Situational low self-esteem C. Ineffective coping D. Altered thought processes E. Altered sensory perception ANS: A, B, C The mastectomy is likely to disturb the clients body image. She is ineffectively coping by withdrawing. She may be experiencing negative feelings about herself related to her altered body image, which would result in low self-esteem. None of the symptoms presented indicate a problem with either altered thought or altered sensory perception.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

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Chapter 16. Anger/Aggression Management Multiple Choice 1. A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, How will we know if someone may get violent? Which is the most appropriate reply by the nursing instructor?

A. You cant really say for sure. There are limited indicators of potential violence.

B. Certain behaviors indicate a potential for violence. They are labeled as a prodromal syndrome and include rigid posture, clenched fists, and raised voice.

C. Any client can become violent, so it is best to be aware of your surroundings at all times.

D. When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence.

ANS: B These behaviors have been identified as predictors of violent behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 2. A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction?

A. Anger is physiological arousal.

B. Anger and aggression are essentially the same.

C. Anger expression is a learned response.

D. Anger is not a primary emotion.ANS: B Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. Which client statement demonstrates improvement in anger/aggression management?

A. I realize I have a problem expressing my anger appropriately.

B. I know I cant use physical force anymore, but I can intimidate someone with my words.

C. Its bad to feel as angry as I feel. Im working on eliminating this poisonous emotion entirely.

D. Because my wife seems to be the one to set me off, Ive decided to remain separated from her.ANS: A The client is recognizing and taking responsibility for personal anger.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited?

A. The defense mechanism of projection

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B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement ANS: D Anger can lead to aggression when the coping response is displacement. This client has discharged anger against a person (the nurse) unrelated to the true target of the anger (the spouse).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression?

A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents ANS: D An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal?

A. 1 hour B. 2 hours C. 3 hours D. 4 hours ANS: D The Joint Commission (JCAHO) requires that a physician or licensed independent provider (LIP) must reissue a new order for restraints every 4 hours for adults, every 1 hour for clients younger than 9, and every 2 hours for clients 9 to 17 years.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 7. An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary?

A. I hate all of you!B. My fingers are tingly.

C. You wait until I tell my lawyer.

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D. I have a sinus headache.ANS: B This statement may mean that the restraints are excessively tight and impeding circulation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 8. After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the clients return to the therapeutic milieu. Which unit procedure is the staff implementing?

A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing ANS: D Debriefing is an important part of restraint/seclusion. It allows the staff an opportunity to review and learn from the experience and to express feelings generated by the incident.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 9. Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards?

A. The patient must be let out of restraint.

B. A physician or other licensed independent practitioner must conduct an in-person evaluation.

C. The patient must be bathed and fed.

D. The patient must be included in debriefing.

ANS: B Joint Commission (JCAHO) standards require that a physician or other licensed independent practitioner conduct an in-person evaluation of the client within 1 hour of the initiation of restraint.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 10. For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise?

A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting.

B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others.

C. Clients with antisocial tendencies need to submit to authority.

D. Clients with behavioral dysfunction need behavioral interventions.

ANS: B Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves

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or others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 11. A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns Risk for other-directed violence as the clients priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client?

A. The client will not verbalize anger or hit anyone.

B. The client will verbalize anger rather than hit others.

C. The client will not inflict harm on others during this shift.

D. The client will be restrained if verbal or physical abuse is observed during this shift.ANS: C Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer A does not contain a time frame.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 12. At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client.

To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation?

A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the clients case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist ANS: B To meet Joint Commission standards, an in-person evaluation by a physician or LIP should be conducted within 1 hour of the initiation of restraints.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 13. Which risk factor should a nurse recognize as the most reliable indicator of potential client violence?

A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter ANS: B A prior history of assault is the most widely recognized risk factor for client violence.

KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 14. A nursing instructor is teaching about violence-intervention protocols. Which student statement would

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indicate the need for further instruction?

A. Administering psychotropic medications can be a part of violence-intervention protocols.

B. Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols.

C. Applying leather restraints can be a part of violence-intervention protocols.

D. Calling for assistance is a part of violence-intervention protocols. ANS: B Touching the client could be seen by him or her as threatening and provoke further violence.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 15. A client begins to smash furniture, cannot be talked down, and refuses medications. Which is the most appropriate nursing intervention?

A. Call a violence code.

B. Ask the ward clerk to put in a call for the physician.

C. Place the client in seclusion.

D. Place the client in four-point restraints.ANS: A In this situation the nurse must have adequate, trained help to prevent injury to the client or staff. Calling a violence code will access this help.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the clients restraint order?

A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order ANS: B The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 17. A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall.

Which should be the initial nursing action?

A. Assertively instruct the client to stop punching the wall.

B. Encourage the client to write down feelings in a journal.

C. With the help of staff, initiate seclusion protocol.

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D. Ensure adequate physical space between the nurse and the client.

ANS: D To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 18. The nurse observes a clients escalating anger. The client begins to pace the hall and shouts, You all better watch out. Im going to hurt anyone who gets in my way. Which should be the priority nursing intervention?

A. Calmly tell the client, Staff will help you to control your impulse to hurt others.

B. Remove other clients from the area and maintain milieu safety.

C. Gather a show of force by contacting security for assistance.

D. Calmly tell the client, You will need to be medicated and secluded.

ANS: B During an emergent situation on an inpatient unit, the nurses priority action should be to keep all clients safe by removing them from the area of conflict.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 19. The client states, I get into trouble because I respond violently without thinking. That usually gets me into a mess. Which nursing reply would be most therapeutic to address this clients problem?

A. Everybody loses their temper. Its good that you know that about yourself.

B. Ill bet you have some interesting stories to share about overreacting.

C. Lets explore methods to help you stop and think before taking action.

D. Its good that you are showing readiness for behavioral change.

ANS: C Helping the client to find alternative ways to release tension by more appropriate problem-solving behaviors is a therapeutic nursing intervention.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 20. Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out?

A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Reflecting back to the client empathy about the clients distress D. Presenting appropriate values that need to be modified ANS: C

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Reflecting back to the client empathy about the clients distress promotes a trusting relationship and may prevent the clients anxiety from escalating when limits are set.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 21. Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client?

A. Place a hand on the clients shoulder and state, I will help you to your room.

B. Slowly and matter-of-factly state, I am your nurse and I will show you to your room.

C. Firmly set limits by stating, If your behavior does not improve you will be secluded.

D. Smile and state, I am your nurse. When do you want to go to your room?

ANS: B It is important to maintain an unemotional tone of voice when dealing with a hostile client. The client might misinterpret touch and become violent.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 22. A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply.

A. Acknowledge the clients behavior.

B. Initiate forced medication protocol.

C. Assist the client to a quiet area.

D. Initiate confinement measures.

E. Speak with a soft and calming voice.

ANS: A, C, E The nurse should remain calm when dealing with an angry client. It is important to acknowledge the clients behavior and assist the client to a less stimulating environment.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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Chapter 17. The Suicidal Client Multiple Choice 1. A nurse discovers a clients suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action?

A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the clients threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the clients threat must be addressed ANS: C The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 2. During the planning of care for a suicidal client, which correctly written outcome should be a nurses first priority?

A. The client will not physically harm self.

B. The client will express hope for the future by day 3.

C. The client will establish a trusting relationship with the nurse.

D. The client will remain safe during the hospital stay.

ANS: D The nurses priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurses priority. The A answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, and realistic and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding selfharm. The client refuses to commit to developing a plan for safety. What should be the nurses priority intervention at this time?

A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide ANS: C The nurses priority intervention when a client hears voices commanding self-harm is to place the client on one-

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to-one observation while continuing to monitor suicidal ideation.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurses priority at this time?

A. Give the client off-unit privileges as positive reinforcement.

B. Encourage the client to share mood improvement in group.

C. Increase frequency of client observation.

D. Request that the psychiatrist reevaluate the current medication protocol.

ANS: C The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out selfdestructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 5. A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this clients safety upon discharge?

A. Provide a 6-month supply of Elavil to ensure long-term compliance.

B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.

C. Provide a pill dispenser as a memory aid.

D. Provide education regarding the avoidance of foods containing tyramine.

ANS: B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the clients safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment: Management of Care 6. During a one-to-one session with a client, the client states, Nothing will ever get better, and Nobody can help me. Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time?

A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements ANS: D

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The clients statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the clients suicidal ideations and intent would be necessary.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the teams decision?

A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation ANS: D Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 8. The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide?

A. Address only serious suicide threats to avoid the possibility of secondary gain.

B. Promote trust by verbalizing a promise to keep suicide attempt information within the family.

C. Offer a private environment to provide needed time alone at least once a day.

D. Be available to actively listen, support, and accept feelings.

ANS: D Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 9. A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information?

A. Your grieving will subside within 1 year; until then I recommend antidepressants.

B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area.

C. The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them.

D. Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone.

ANS: B Bereavement following suicide is complicated by the complex psychological impact of the act on those close

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to the victim. Support groups for survivors can provide a meaningful resource for grief work.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 10. After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care?

A. Have there been any changes in appetite or sleep?

B. How often is your spouse left alone?

C. Has your spouse been following a diet and exercise program consistently?

D. How would you characterize your relationship with your spouse?

ANS: B This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include?

A. Elderly people use less lethal means to commit suicide.

B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides.

C. Suicide is the second leading cause of death among the elderly.

D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

ANS: B This factual information should be included in the nursing instructors teaching plan. An expressed desire to die is not normal in any age group.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 12. A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, Im going to use a knotted shower curtain when no one is around. Which information would determine the nurses plan of care for this client?

A. The more specific the plan is, the more likely the client will attempt suicide.

B. Clients who talk about suicide never actually commit it.

C. Clients who threaten suicide should be observed every 15 minutes.

D. After a brief assessment, the nurse should avoid the topic of suicide.

ANS: A Clients who have specific plans are at greater risk for suicide.

KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Safe and Effective

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Care Environment 13. A suicidal client says to a nurse, Theres nothing to live for anymore. Which is the most appropriate nursing reply?

A. Why dont you consider doing volunteer work in a homeless shelter?

B. Lets discuss the negative aspects of your life.

C. Things will look better in the morning.

D. It sounds like you are feeling pretty hopeless.

ANS: D This statement verbalizes the clients implied feelings and allows him or her to validate and explore them.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse managers best reply?

A. Suicide is a DSM-5 diagnosis.

B. Suicide is a mental disorder.

C. Suicide is a behavior.

D. Suicide is an antisocial affliction.

ANS: C Suicide is not a diagnosis, disorder, or affliction. It is a behavior.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first?

A. Communicate therapeutically.

B. Observe the client.

C. Provide a hazard-free environment.

D. Assess suicide risk.

ANS: D Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self?

A. The client will not physically harm self.

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B. The client will express three positive self-attributes by day 4.

C. The client will reveal a suicide plan.

D. The client will establish a trusting relationship.

ANS: B Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, and measureable and contain a time frame.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 17. A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred?

A. Suicidal threats and gestures should be considered manipulative and/or attention-seeking.

B. Suicide is the act of a psychotic person.

C. All suicidal individuals are mentally ill.

D. Fifty to eighty percent of all people who kill themselves have a history of a previous attempt.

ANS: D It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt.

All other answer choices are myths about suicide.

KEY: Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Safe and Effective Care Environment 18. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each clients belief system, the nurse should conclude which client would potentially be at highest risk for suicide?

A. Roman Catholic B. Protestant C. Atheist D. Muslim ANS: C Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment 19. Which nursing intervention strategy is most appropriate to implement initially with a suicidal client?

A. Ask a direct question such as, Do you ever think about killing yourself?

B. Ask client, Please rate your mood on a scale from 1 to 10.

C. Establish a trusting nurseclient relationship.

D. Apply the nursing process to the planning of client care.

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ANS: A The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 20. A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this clients risk for suicide?

A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times ANS: C The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 21. Which client data indicate that a suicidal client is participating in a plan for safety?

A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse ANS: C A degree of the responsibility for the suicidal clients safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 22. Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge?

A. I must observe you continually for 1 hour in order to keep you safe.

B. Lets confer with the treatment team about the resources that you may need after discharge.

C. You must have been very upset to do what you did today.

D. Are you currently thinking about harming yourself?

ANS: B The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss

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client problems and needs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 23. A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide?

A. Family history of depression B. The clients orientation to reality C. The clients history of suicide attempts D. Family support systems ANS: C A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the clients risk.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 24. A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation?

A. Assessing the clients pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurseclient relationship ANS: A It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslows hierarchy of needs. This clients problems with oxygenation will take priority over assessing for current suicidal ideations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment Multiple Response 25. After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply.

A. I cant believe this is happening.

B. If only I had been more understanding.

C. How dare he do this to me!

D. Im just going to have to accept that he was gay.

E. Well, that was a selfish thing to do.

ANS: A, B, C

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Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father. The last two possible responses suggest acceptance and understanding. It is far more common for survivors of suicide to have a sense of feeling wounded and as if they will never get over it.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply.

A. In the Middle Ages, suicide was viewed as a selfish and criminal act.

B. During the Roman Empire, suicide was followed by incineration of the body.

C. Suicide was an offense in ancient Greece, and a common-site burial was denied.

D. During the Renaissance, suicide was discussed and viewed more philosophically.

E. Old Norse traditionally set a person who committed suicide adrift in the North Sea. ANS: A, C, D These are true historical facts about suicide and should be included in the students study guide.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

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Chapter 18. Behavior Therapy Multiple Choice 1. A kindergarten rule states that if unacceptable behavior occurs, a childs personalized fish will be moved to the sea grass. Children who behave keep their fish out of the sea grass. The school nurse should identify this intervention as based on which principle of behavior therapy?

A. Classical conditioning B. Conditioned response C. Positive reinforcement D. Negative reinforcement ANS: D Negative reinforcement is increasing the probability that behavior (appropriate classroom behavior) will recur by removal of an undesirable reinforcing stimulus (personalized fish in sea grass).

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. An adolescent comes from a dysfunctional family where physical and verbal abuse prevails. At school this adolescent bullies and fights with classmates. According to principles of behavior therapy, what is the probable source of this behavior?

A. Shaping B. Modeling C. Premack principle D. Reciprocal inhibition ANS: B Modeling is the learning of new behaviors by imitating the behaviors of others. This adolescent, witnessing physical and verbal abuse in the home, models this behavior in school.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 3. A third-grader feigns illness in order to avoid doing homework. The teacher recommends an educational program that uses a token economy. How should a school nurse explain a token economy to this childs parent?

A. Your child will receive green tokens for completing homework that can be cashed in for desired rewards.

B. Your child will receive red tokens when homework is incomplete and this will result in school suspension.

C. Your child will receive a time out for each homework assignment not completed.

D. Your child, with your assistance, will envision receiving rewards for completed homework.

ANS: A In a token economy, tokens are a form of contingency contracting in that tokens immediately reinforce appropriate behavior (completed homework) and are exchanged later for a desired reward.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:

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Psychosocial Integrity 4. A client is diagnosed with an anxiety disorder. The nurse counselor recommends intervention with the behavioral technique of reciprocal inhibition. The client asks, Whats that? Which is the most appropriate nursing reply?

A. At the beginning of this intervention, a contract will be drawn up explicitly stating the behavior change agreed upon.

B. By introducing an adaptive behavior that is mutually exclusive to your maladaptive behavior, we will expect subsequent behavior to improve.

C. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.

D. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.

ANS: B Reciprocal inhibition decreases or eliminates an undesired behavior by introducing a more adaptive behavior that is incompatible with the undesired behavior.

KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Psychosocial Integrity 5. A client reports, My friend panicked at the site of spiders. Her therapist used gradual exposure to spiders that initially made her increasingly more anxious. Which technique was the friends therapist most likely using?

A. Extinction B. Covert sensitization C. Systematic desensitization D. Reciprocal inhibition ANS: C Systematic desensitization is a treatment for phobias in which a phobic individual is gradually exposed to increasing amounts of the phobic stimulus while practicing relaxation techniques. Eventually, the phobic stimulus causes little or no anxiety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 6. A 2-year-old engages in frequent temper tantrums that usually result in the parents giving in to demands.

During family therapy, how should a nurse counsel the parents?

A. You are shaping your childs behavior.

B. Your child has modeled your behavior.

C. You are positively reinforcing your childs behavior.

D. You are negatively reinforcing your childs behavior.

ANS: C KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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7. A child always chooses to ask mother over father when seeking special privileges. The father is more apt to disagree than agree with the childs requests, whereas the mother usually consents. The childs choice is the result of which component of operant conditioning?

A. Conditioned stimuli B. Unconditioned stimuli C. Aversive stimuli D. Discriminative stimuli ANS: D This child is able to discriminate between stimuli. This child can predict with assurance that asking mother (not father) will result in a desired response.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 8. Parents decide to try the nurse practitioners suggestion of time out when their child misbehaves. What teaching should the nurse practitioner provide the parents?

A. Correct your childs behavior by spanking for a specified time period.

B. Ignore the childs negative behavior.

C. Add positive reinforcement for acceptable behavior.

D. Temporarily move your child to an area where behavior is not being reinforced.

ANS: D A time out is an aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is occurring. Usually during a time out, the person is temporarily isolated so there is no reinforcing attention. This discourages a reoccurrence of the undesired behavior.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 9. Parents of a 3-year-old have noticed an improvement in behavior because of using a time out behavioral approach. What aspect of time out therapy may be responsible for this childs improved behavior?

A. Negative reinforcement discourages maladaptive behavior.

B. Positive reinforcement is removed.

C. Covert sensitization is being applied.

D. Reciprocal inhibition is eliminated.

ANS: B In a time out, the positive reinforcement of attention is removed from the child during inappropriate behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 10. A client is in therapy with a nurse practitioner for the treatment of arachnophobia. The nurse practitioner decides to use the technique of flooding. Which intervention best exemplifies this technique?

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A. Giving rewards for demonstrating a decrease in fear of spiders B. Encouraging the client to sit through the movie Spiderman C. Accompanying the client to a 1-hour visit to the local zoos spider room D. Offering a computer program that progressively presents anxiety-producing spider scenarios ANS: C Visiting the spider room would flood the client with the phobic stimuli of real spiders. This would continue until the stimulus no longer creates anxiety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. During a smoking cessation group, the community health nurse explains that in their effort to quit smoking, a reciprocal inhibition approach will be used. The nurse should give the group which example of this technique?

A. Before you can smoke, you must first take a half-hour walk.

B. When you have the urge to smoke, imagine being short of breath.

C. Youll receive $1 for each cigarette not smoked and forfeit $2 for each cigarette smoked.

D. When you have the urge to smoke, hold your breath and then rhythmically breathe.

ANS: D These breathing exercises cannot be done while the client smokes. Therefore, they decrease or eliminate the undesired behavior (smoking) that is incompatible with the desired behavior (smoking cessation). This is an example of the behavior therapy of reciprocal inhibition.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. A mother states, You are old enough to clean your own bedroom. Later inspection finds the floor clear, but with everything stacked in a chair. The mother praises the child for clearing the floor. This is consistent with which technique of behavior modification?

A. Shaping B. Extinction C. Stimulus generalization D. Reciprocal inhibition ANS: A In shaping, behavior is molded in a desired direction by reinforcing each small step toward the desired behavior. The child is praised for clearing the floor, the first step toward cleaning the room.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 13. During hospitalization, an attention-seeking client has repeatedly cut herself. After threatening to cut herself again, the nurse states, Here are some Band-Aids so you wont bleed on the sheets. Which is the underlying reason for this nurses response?

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A. The nurse is using an aversive stimulus in response to the clients manipulative cutting behavior.

B. The nurse is using negative reinforcement in response to the clients behavior.

C. The nurse is minimizing reinforcement of the clients manipulative behavior with the goal of extinction.

D. The nurse lacks empathy for the clients recurring self-injurious behavior.

ANS: C Extinction is the gradual decrease in frequency or disappearance of a response when a positive reinforcement is withheld. The nurse is withholding attention to the client who is exhibiting manipulative, attention-seeking behavior. The lack of positive response (attention) should cause extinction of the undesired behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. A nursing instructor is teaching about the behavior technique of modeling. When asked to give an example of this behavioral intervention, which student statement meets the learning objective?

A. A child is first rewarded for using a spoon to eat and then rewarded for using a fork, and finally rewarded for cutting food with a knife.

B. An adolescent imitates Dad by using and caring for tools appropriately.

C. A client and therapist agree to conditions of therapy, stating explicitly in writing the behavior change that is desired.

D. A mother tells her child that television can be watched only after homework is completed.

ANS: B Modeling refers to the learning of new behaviors by imitating the behavior of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 15. A mother tells her teenager that in order for college tuition to be paid, the teenager must quit smoking.

They develop a written agreement stipulating time frames and consequences. This is an example of which technique of behavior modification?

A. Shaping B. Modeling C. Contracting D. Premack principle ANS: C Contracting occurs when the mother and teenager together develop a written agreement related to desired behavior (smoking cessation) and positive reinforcement (paid college tuition).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 16. When asked to identify principles that define the term maladaptive behavior, which nursing student statement indicates that further teaching is needed?

A. Behavior is maladaptive when it is age inappropriate.

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B. Behavior is maladaptive when it interferes with adaptive functioning.

C. Behavior is maladaptive when it is identified as inappropriate in the context of ones culture.

D. Behavior is maladaptive when it results in change within an otherwise stable subsystem.

ANS: D Behaviors that result in change within a subsystem, even when it is stable, could be either adaptive or maladaptive behaviors. This statement, therefore, is incorrect.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 17. Which assumption is most reflective of a behavioral theory model?

A. Mental illness is characterized by structural and biochemical alterations.

B. Thought processes influence behaviors.

C. All personality development has a social context.

D. There is a basic relationship between stimulus and response.

ANS: D That there is a basic relationship between stimulus and response is an assumption of a behavioral theory model.

The connection between a stimulus and a response is strengthened or weakened by the consequences of the response.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. A nurse should recognize which intervention as most appropriate within a behavioral therapy program?

A. A child is given a Popsicle for staying dry and clean.

B. A child is put in time-out after soiling his or her undergarments.

C. A child is allowed to remain in soiled undergarments.

D. A child is taught the advantages of staying dry and clean.

ANS: A A stimulus that follows a behavior or response is called a reinforcing stimulus or reinforcer. The reward of a Popsicle is a reinforcer for the child staying dry and clean. This is an example of operant conditioning, a form of behavioral therapy.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. The nurse should initially implement which nursing action?

A. Redirect the client to activities to decrease stress.

B. Explain the unit rules and consequences of breaking the rules.

C. Place the client on close observation to insure a trusting relationship.

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D. Administer an anti-anxiety medication.

ANS: B It is important for the nurse to initially explain the unit rules and consequences of breaking the rules. It is imperative that consequences of rule infractions are explained early in treatment to avoid misunderstanding and manipulation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 20. According to behavioral theory, the treatment of phobic symptoms should involve which action?

A. The manipulation of the environment B. The use of desensitization C. The use of family therapy D. The uncovering of past events ANS: B Systematic desensitization is a technique for assisting individuals to overcome their fear of a phobic stimulus.

It is systematic in that there is a hierarchy of anxiety-producing events through which the individual progresses during therapy.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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Chapter 19. Cognitive Therapy Multiple Choice 1. A nursing instructor is teaching about the didactic aspects of cognitive therapy. Which student statement indicates a deficit in meeting the learning objectives of this content?

A. The therapist provides information about the process of cognitive therapy.

B. The therapist uses guided imagery in an effort to elicit automatic thoughts.

C. The therapist provides information about how cognitive therapy works.

D. The therapist uses reading assignments to reinforce learning.

ANS: B Cognitive therapy prepares the client to become his or her own cognitive therapist. The didactic portion of the therapy provides educational material to reinforce learning about the therapy and how it affects psychiatric disorders.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 2. A psychiatric nurse is counseling a client who has thought patterns consisting of rapid responses to a situation without rational analysis. What assessment data will the nurse document on this client?

A. Thought patterns are triggered by specific stressful stimuli.

B. Thought patterns contain the clients fundamental beliefs and assumptions.

C. Thought patterns are flexible and based on personal experience.

D. Thought patterns include a predominance of automatic thoughts.

ANS: D According to Beck, automatic thoughts consist of rapid responses to a situation without rational analysis.

These thoughts are often negative and based on erroneous logic.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. A successful business executive continually thinks that job accomplishments are not adequate. A nurse recognizes that the clients thinking is reflective of which cognitive error?

A. Minimization B. Dichotomous thinking C. Arbitrary inference D. Personalization ANS: A Minimization is the cognitive error that undervalues positive events and experiences. The client cannot give credit for personal strengths.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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4. A nursing student states, The instructor gave me a failing grade on my research paper. I know its because the instructor doesnt like me. Which cognitive error does a nurse recognize in this students statement?

A. Dichotomous thinking B. Catastrophic thinking C. Magnification D. Overgeneralization ANS: C In magnification, negative events are exaggerated. It is irrational to assume that there is a relationship between failing a paper and being personally disliked by the instructor.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. An advanced practice nurse recommends that a client participate in cognitive therapy. The client asks, Whats cognitive therapy and how can it help me? Which is the nurses most appropriate reply?

A. It is a system of techniques in which you use positive thinking to improve your mood.

B. It is a long-term interpersonal approach that emphasizes the role of early childhood experiences.

C. It is an interpersonal treatment approach that specifically targets magical thinking.

D. It is a type of psychotherapy that focuses treatment on the modification of distorted thinking and maladaptive behaviors.

ANS: D Cognitive therapy is meant to be a time-limited intervention in which the therapist works in collaboration with the client to modify thinking to eliminate cognitive errors that reinforce emotional disturbances.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. A welder has been selected as employee of the year. The welder wants to ask for a promotion but is hampered by poor self-esteem. The employee health nurse provides assistance. Which technique should the nurse use to help the employee request the promotion?

A. Socratic questioning B. Activity scheduling C. Distraction D. Cognitive rehearsal ANS: D Cognitive rehearsal allows the employee to uncover potential automatic thoughts in advance of his or her meeting to request a promotion. This allows the employee to develop strategies to modify any dysfunctional thinking.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. An advanced practice nurse is counseling a client diagnosed with generalized anxiety disorder. The nurse

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plans to use activity scheduling to address this clients concerns. What is the purpose of this nursing intervention?

A. To identify important areas needing concentration during therapy B. To increase self-esteem and decrease feelings of helplessness C. To modify maladaptive behaviors by the use of role-play D. To divert away from intrusive thoughts and depressive ruminations ANS: A In activity scheduling, the client is asked to keep a daily log of activities and rate them for mastery and pleasure in order to identify recurring daily patterns that may need to be addressed in therapy.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. When a clients husband comes home late from work, the wife immediately fears infidelity. The advanced practice nurse therapist encourages the wife to consider other explanations for her husbands tardiness. What technique is the nurse using?

A. Examination of the evidence B. Decatastrophizing C. Generating alternatives D. Reattribution ANS: C Using the technique of generating alternatives will assist the client to recognize a wider range of possible explanations for her husbands behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 9. A nursing student evaluates her group project partner as irresponsible because of minimal participation in planning. When told of this situation, the nursing instructor plans to use the cognitive technique of examining the evidence. Which response exemplifies this technique?

A. Lets look at the potential reasons why your partner has not participated.

B. How would you define irresponsibility?

C. Has it occurred to you that your partner may be working on the project at home?

D. Are you telling me that you feel totally responsible for this project?

ANS: A When using the technique of examining the evidence, the student and nurse review automatic thoughts and study the evidence to support or counter the belief.

KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Psychosocial Integrity 10. A nursing assistant has failed a prerequisite course toward admission to nursing school and states, I will always be only a nursing assistant and never an RN. Her nursing advisor understands this is an example of

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which automatic thought?

A. Arbitrary inference B. Overgeneralization C. Dichotomous thinking D. Personalization ANS: B Overgeneralization occurs when sweeping conclusions are made on the basis of one incident. Because the student failed a prerequisite nursing course, the student overgeneralizes that the goal of being an RN will never be attained.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. A high school basketball player sustains a serious knee injury and states to the school nurse, I will never get to college if I dont receive a basketball scholarship. Which nursing reply would assist the student to see a broader range of possibilities?

A. Lets look at the alternatives for funding your college education.

B. I know you are feeling helpless now, but you are looking at this from only one perspective.

C. Can your family afford knee surgery?

D. You now need to prioritize your academics and not focus on basketball.

ANS: A When the nurse helps the student to see a broader range of possibilities, the nurse is using the cognitive technique of generating alternatives.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. A labor and delivery nurse listens to a new mother relate thoughts regarding her healthy, 8-pound baby girl.

Which statement by the mother indicates to the nurse the use of the cognitive error, selective abstraction?

A. My baby is refusing to nurse, and I know its because she hates me.

B. My baby needs to be under the bilirubin lights, but I resent her time away from me.

C. My baby is wonderful, but Im depressed because I wanted twins.

D. My baby has an elevated bilirubin, and I know it will get worse and she will die.

ANS: C In selective abstraction the individual focuses attention on evidence that is viewed as a failure (not having twins) rather than any successes (a healthy baby) that have occurred.

KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Psychosocial Integrity 13. A client admitted to a Veterans Administration (VA) hospital with a diagnosis of major depressive disorder tells the nurse, I failed my battalion by giving the wrong order. Fortunately, no one was injured. Which nursing diagnosis should the nurse assign to this client?

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A. Chronic low self-esteem B. Risk for self-directed violence C. Powerlessness D. Situational low self-esteem ANS: D Emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues.

The nursing diagnosis of situational low self-esteem is used for individuals who have a negative perception of self-worth in response to a current situation. This clients cognitive appraisal of the situation has led to the diagnosis of major depressive disorder and low self-esteem.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 14. The director of nursing (DON) sets up a meeting with the newly appointed nurse manager, who, to this point, has done an excellent job. The nurse manager anticipates job termination. What is the best description of the cognitive error being employed by the nurse manager?

A. Thinking from an all-or-nothing perspective B. Always thinking the worst will occur without considering positive outcomes C. Viewing only selected negative evidence while editing out positive aspects D. Undervaluing the positive significance of an event ANS: B Catastrophic thinking involves always thinking that the worst will occur without considering the possibility of more likely positive outcomes. The nurse manager has quickly jumped to the conclusion that the meeting will result in job termination.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. A nursing instructor is teaching about dichotomous thinking. Which student statement indicates that learning has occurred?

A. Dichotomous thinking is when an individual views situations as being good or bad or black or white.

B. Dichotomous thinking is when an individual takes complete responsibility for situations without considering other circumstances.

C. Dichotomous thinking is when an individual exaggerates the negative significance of an event.

D. Dichotomous thinking is when an individual undervalues the positive significance of an event.

ANS: A An individual who is using dichotomous thinking views situations in terms of all or nothing, good or bad, or black or white.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 16. A client states, I keep having horrible nightmares about the car accident that killed my daughter. I shouldnt have taken her with me to the store. Using a cognitive approach, which nursing reply would be most

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therapeutic?

A. Are other issues from your past affecting your ability to move on?

B. Describe your current feelings about your loss.

C. Lets talk about something that will help you move on.

D. Can anyone predict when a car accident will happen?

ANS: D When the nurse attempts to encourage the client to reframe thoughts, the nurse is using a cognitive approach.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. Which client statement would exemplify the level of cognitive function that you would expect to see in mild anxiety?

A. Right now I feel as sharp as a tack.

B. Im having a tough time focusing.

C. Sometimes I feel like Im having an out-of-body experience.

D. All I seem to focus on is my anger.

ANS: A Cognitive ability will be enhanced with mild anxiety. Mild anxiety prepares the individual for heightened responses to environmental stimuli.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. When using a cognitive approach, a nurse would include which point in teaching a client about panic disorder?

A. You might want to stay in the house when you notice the symptoms beginning.

B. Medications such as lorazepam (Ativan) should be taken when symptoms start.

C. Remind yourself that symptoms of a panic attack are time limited and will end.

D. Keep a journal in order to note feelings surrounding the panic attacks.

ANS: C When a nurse reminds a client that symptoms of a panic attack are time limited and will end, the nurse is using the cognitive approach of presenting rational thinking.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. Using a cognitive approach, a nurse would choose which intervention for assisting clients to manage their anger without the use of violence?

A. Assist the client to identify thoughts that trigger anger and substitute reality-based thinking.

B. Provide consequences, such as removal from group therapy, in response to angry outbursts.

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C. Administer antipsychotic medications and use limit-setting such as a room restriction.

D. Administer anti-anxiety medication and encourage participation in a group on medication actions.

ANS: A By assisting the client to identify thoughts that trigger anger and encourage the substitution of more realitybased thinking, the nurse can help the client to alter dysfunctional beliefs that predispose the client to distort experiences.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 20. A client recovering from alcohol toxicity is using minimization. Which statement reflects this cognitive distortion?

A. I cant give up alcohol right now because I just gave up smoking.

B. I just read that red wine has health benefits.

C. I may have a minor problem, but I can handle it.

D. I dont drink as much as my wife, and nobody thinks she has a problem.

ANS: C The statement I may have a minor problem, but I can handle it is an example of the use of the cognitive distortion of minimization. Minimization is the undervaluing of the positive significance of an event.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 21. A client is experiencing auditory hallucinations. Using a cognitive strategy, the nurse would encourage the client to do which of these?

A. Try singing Happy Birthday until the voices are gone.

B. Document what the voices are saying, to note cause and effect.

C. Try listening to music using headphones for distraction.

D. Remind yourself that the voices are symptoms of your disease.

ANS: D The focus of cognitive therapy is on the modification of distorted cognitions and maladaptive behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 22. A client diagnosed with borderline personality disorder states, Get out of here. No one cares about me or my situation! Which nursing reply is an example of a cognitive intervention?

A. You have an anti-anxiety medication ordered. It may make you feel better.

B. It sounds like you are feeling really frustrated.

C. Can you explain further your thinking about your situation?

D. No one cares about you?

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ANS: C When a nurse asks for an explanation about a clients thinking, the nurse is using a cognitive approach to assessment. The focus of cognitive interventions is on the modification of distorted cognitions and maladaptive behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 23. A nursing instructor is lecturing about cognitive therapy. Which of the following are objectives when implementing this therapy? Select all that apply.

A. To modify automatic thoughts to promote minimization of negative cognitions B. To apply a variety of methods to create change in an individuals thinking C. To apply cognitive principles in order to change an individuals basic schema D. To modify belief systems in an effort to bring about emotional change E. To modify belief systems in an effort to bring about behavioral change ANS: B, D, E In cognitive therapy, the therapists objective is to use a variety of methods to create change in a clients thinking and belief system, in an effort to bring about lasting emotional and behavioral change.

KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 24. A nurse practitioner uses cognitive therapy with depressed clients. The nurse asks clients to keep a daily record of dysfunctional thoughts. Which of the following are appropriate nursing replies to a client questioning the purpose of this exercise? Select all that apply.

A. The purpose of this exercise is to identify automatic thoughts.

B. The purpose of this exercise is to identify rational alternatives.

C. The purpose of this exercise is to modify cognitive errors.

D. The purpose of this exercise is to eliminate irrational beliefs.

E. The purpose of this exercise is to monitor thoughts related to self-esteem.

ANS: A, B, C In a daily record of dysfunctional thoughts, clients (1) identify automatic thoughts and (2) generate a more rational response. In this way, the tool serves to help them (3) modify or make changes in their thinking. A daily record of dysfunctional thoughts does not eliminate the occurrence of irrational beliefs or monitor thoughts solely related to self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 25. Which of the following client statements would indicate that teaching about benzodiazepines has been successful? Select all that apply.

A. I cant drink alcohol when taking lorazepam (Ativan).

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B. If I abruptly stop taking buspirone (BuSpar), I may have a seizure.

C. Valium can make me drowsy, so I shouldnt drive for awhile.

D. My new diet cannot include aged cheese or pickled herring.

E. When the fluoxetine (Prozac) begins working, I can stop the alprazolam (Xanax).

ANS: A, C When a nurse teaches about medications, he or she is using a cognitive approach. A core concept of cognitive theory relates to the mental process of thinking and reasoning.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

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Chapter 20. Electroconvulsive Therapy Multiple Choice 1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurses rationale for this procedure?

A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medication-induced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 2. Immediately after electroconvulsive therapy, in which position should a nurse place the client?

A. On his or her side to prevent aspiration B. In semi-Fowlers position to promote oxygenation C. In Trendelenburgs position to promote blood flow to vital organs D. In prone position to prevent airway blockage ANS: A The nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 3. A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred?

A. During ECT a state of euphoria is induced.

B. ECT induces a grand mal seizure.

C. During ECT a state of catatonia is induced.

D. ECT induces a petit mal seizure.

ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

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4. A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention?

A. Suicide assessment must continue throughout the ECT course.

B. Antidepressant medications are contraindicated throughout the ECT course.

C. Discourage expressions of hopelessness throughout the ECT course.

D. Encourage a high-caloric diet throughout the ECT course.

ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom. Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 5. After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, I cant even remember eating breakfast, so I want to stop the ECT. Which is the most appropriate nursing reply?

A. After you begin the course of treatments, you must complete all of them.

B. Youll need to talk with your doctor about what youre thinking.

C. It is within your right to discontinue the treatments, but lets talk about your concerns.

D. Memory loss is a rare side effect of the treatment. I dont think it should be a concern.

ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the clients concerns so that the nurse can provide needed information.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 6. Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, Im not hungry and just want to stay in bed and sleep. On the basis of this information, which is the most appropriate nursing intervention?

A. Allow the client to remain in bed.

B. Encourage the client to join the milieu to promote socialization.

C. Obtain a physicians order for parenteral nutrition.

D. Involve the client in physical activities to stimulate circulation.

ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 7. A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a clients

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electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication?

A. Robinul decreases anxiety during the ECT procedure.

B. Robinul induces an unconscious state to prevent pain during the ECT procedure.

C. Robinul prevents severe muscle contractions during the ECT procedure.

D. Robinul decreases secretions to prevent aspiration during the ECT procedure.

ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT procedures to decrease secretions and prevent aspiration.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred?

A. Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT. B. Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration.

C. Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious.

D. Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure.

ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously a short-acting anesthetic such as thiopental sodium (Pentothal).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action?

A. The nurse notifies the clients physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room.

C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m.

D. The nurse increases the clients fluid intake to facilitate the digestive process.

ANS: A A client who is scheduled for ECT procedures is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential 10. A client who is learning about electroconvulsive therapy (ECT) asks a nurse, Isnt this treatment dangerous?

Which is the most appropriate nursing reply?

A. No, this treatment is side-effect free.

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B. There can be temporary paralysis, but full functioning returns within 3 hours of treatment.

C. There are some risks, but a thorough examination will determine your candidacy for ECT. D. Transient ischemic attacks (TIAs) can occur but are rare.

ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Reduction of Risk Potential 11. A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve?

A. The client will verbalize an understanding of the need for moving slowly after treatment.

B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment.

C. The client will continue adequate tissue perfusion 1 hour after treatment.

D. The client will verbalize an understanding of common side effects of ECT. ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity 12. A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the clients lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply?

A. The cuff has to be placed on the leg because both arms are used for intravenous fluids.

B. The cuff functions to prevent succinylcholine from reaching the foot.

C. The cuff position gives a more accurate blood pressure reading during the treatment.

D. The cuff is placed on the leg so that arms can easily be restrained during seizure.

ANS: B A blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 13. A client states, My doctor has told me I am a candidate for electroconvulsive therapy (ECT). Where will the treatment take place, and how much time would this entail? Which is the most accurate nursing reply?

A. Clients typically receive ECT in their hospital room, daily for 1 month.

B. Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting.

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C. Clients typically receive an unlimited number of treatments, in the hospital procedure room.

D. Clients typically receive two to three treatments, in either an outpatient or inpatient setting.

ANS: B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures.

Treatments are usually administered every other day, three times per week. Treatments are performed on either an inpatient or outpatient basis, depending on the need for client monitoring.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 14. A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. Which information should a nurse include when teaching about the potential side effects of this procedure?

A. You may experience transient tangential thinking.

B. You may experience some memory deficit surrounding the ECT. C. You may experience avolution for the remainder of the day.

D. You may experience a higher risk for subsequent seizures.

ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 15. When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize?

A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would impact the feasibility of this treatment option?

A. Because the client is extremely suicidal, ECT is an appropriate option.

B. Because antidepressant medications have been ineffective, ECT is a good alternative.

C. Because informed consent is required for ECT, cognitive deficits could preclude this option.

D. Because of the clients cognitive deficits, a signed consent is waived.

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ANS: C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the clients level of competency and, if necessary, the judge would appoint a guardian.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment Multiple Response 17. A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply.

A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression, acute mania, and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 18. Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply.

A. Electrocardiographic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results ANS: A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the clients physician. The client must be medically cleared prior to ECT. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 19. During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply.

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A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated.

KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity 20. Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply.

A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential

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Chapter 21. The Recovery Model Multiple Choice 1. A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed?

A. The goal of recovery is improved health and wellness.

B. The goal of recovery is expedient, comprehensive behavioral change.

C. The goal of recovery is the ability to live a self-directed life.

D. The goal of recovery is the ability to reach full potential.

ANS: B The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental health disorders and substance use disorders as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Change in recovery is not an expedient process. It occurs incrementally over time.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 2. Which situation presents an example of the basic concept of a recovery model?

A. The clients family is encouraged to make decisions in order to facilitate discharge.

B. A social worker, discovering the clients income, changes the clients discharge placement.

C. A psychiatrist prescribes an antipsychotic drug on the basis of observed symptoms.

D. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.

ANS: D The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. A nursing instructor is teaching about the guiding principles of the recovery model, as described by the SAMHSA. Which student statement indicates that further teaching is needed?

A. Recovery occurs via many pathways.

B. Recovery emerges from strong religious affiliations.

C. Recovery is supported by peers and allies.

D. Recovery is culturally based and influenced.

ANS: B SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. Recovery emerges from hope, but

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affiliation with any particular religion would have little bearing on the recovery process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge.

According to the SAMHSA, which dimension of recovery is supporting this client?

A. Health B. Home C. Purpose D. Community ANS: B SAMHSA describes the dimension of Home as a stable and safe place to live.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A client diagnosed with obsessive-compulsive disorder states, I really think my future will improve because of my successful treatment choices. Im going to make my life better. Which guiding principle of recovery has assisted this client?

A. Recovery emerges from hope.

B. Recovery is person-driven.

C. Recovery occurs via many pathways.

D. Recovery is holistic.

ANS: A. The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This client has internalized hope.

This hope is the catalyst of the recovery process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 6. A nurse maintains a clients confidentiality, addresses the client appropriately, and does not discriminate on the basis of gender, age, race, or religion. Which guiding principle of recovery has this nurse employed?

A. Recovery is culturally based and influenced.

B. Recovery is based on respect.

C. Recovery involves individual, family, and community strengths and responsibility.

D. Recovery is person-driven.

ANS: B The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope;

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recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This nurse accepts and appreciates clients who are affected by mental health and substance use problems. This nurse protects the rights of clients and does not discriminate against them.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A nurse on an inpatient unit helps a client understand the significance of treatments and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the Tidal Model of Recovery?

A. Know that Change Is Constant B. Reveal Personal Wisdom C. Be Transparent D. Give the Gift of Time ANS: C Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Be Transparent commitment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. Which is the priority focus of recovery models?

A. Empowerment of the health-care team to bring their expertise to decision-making B. Empowerment of the client to make decisions related to individual health care C. Empowerment of the family system to provide supportive care D. Empowerment of the physician to provide appropriate treatments ANS: B The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step?

A. Step 3: Triggers that cause distress or discomfort are listed.

B. Step 4: Signs indicating relapse are identified and plans for responding are developed.

C. Step 5: A specific plan to help with symptoms is formulated.

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D. Step 6: Following client-designed plan, caregivers now become decision-makers.

ANS: D The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include Step 1, Develop a Wellness Toolbox; Step 2, Daily Maintenance List; Step 3, Triggers; Step 4, Early Warning Signs; Step 5, Things Are Breaking Down or Getting Worse; and Step 6, Crisis Planning. In Step 6 (Crisis Planning), clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed. All other actions presented require the client to be functionally capable.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 10. A nursing instructor is teaching about components present in the recovery process, as described by Andresen and associates, which led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed?

A. A client has a better chance of recovery if he or she truly believes that recovery can occur.

B. If a client is willing to give the responsibility of treatment to the health-care team, he or she is likely to recover.

C. A client who has a positive sense of self and a positive identity is likely to recover.

D. A client has a better chance of recovery if he or she has purpose and meaning in life.

ANS: B In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 11. A client states, My illness is so devastating, I feel like my life is on hold. The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates?

A. Moratorium B. Awareness C. Preparation D. Rebuilding ANS: A Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. The moratorium stage is identified by dark despair and confusion. It is called moratorium, because it seems that life is on hold.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 12. A client states, I have come to the conclusion that this disease has not paralyzed me. The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and

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associates?

A. Moratorium B. Awareness C. Preparation D. Rebuilding ANS: B Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. In the awareness stage, the individual comes to a realization that a possibility for recovery exists. Andresen and associates state, It involves an awareness of a possible self other than that of sick person: a self that is capable of recovery.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 13. A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to find when assessing this client?

A. A client feeling confident about achieving goals in life.

B. A client who is aware of the need to set goals in life.

C. A client who has mobilized personal and external resources.

D. A client who begins to actively take control of his or her life.

ANS: A Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. In the growth stage, the individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 14. Which of the following has the SAMHSA described, as major dimensions of support for a life of recovery?

Select all that apply.

A. Health B. Community C. Home D. Religious affiliation E. Purpose ANS: A, B, C, E SAMHSA suggests that a life in recovery is supported by four major dimensions: health, home, purpose, and

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community. Religious affiliation is not included in the listed dimensions.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. A nurse uses the commitments of the Tidal Model of Recovery in psychiatric nursing practice. Which of the following nursing actions reflect the use of the Develop Genuine Curiosity commitment? Select all that apply.

A. The nurse expresses interest in the clients story.

B. The nurse asks for clarification of certain points.

C. The nurse encourages the client to speak his own words in his own unique way.

D. The nurse assists the client to unfold the story at his or her own rate.

E. The nurse provides the clients with copies of all documents relevant to care.

ANS: A, B, D Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Develop Genuine Curiosity commitment, by expressing interest, asking for clarification, and assisting the client to unfold the story at his or her own rate.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Ordered Response 16. Order the six steps of The Wellness Recovery Action Plan (WRAP) Model as described by Copeland et al.

A.________ Daily Maintenance List B.________ Things Are Breaking Down or Getting Worse C. ________Crisis Planning D.________ Develop a Wellness Toolbox E._________Early Warning Signs F. ________ Triggers ANS: The correct order is 2, 5, 6, 1, 4, 3.

The WRAP model is a step-wise process, through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include Step 1, Develop a Wellness Toolbox; Step 2, Daily Maintenance List; Step 3, Triggers; Step 4, Early Warning Signs; Step 5, Things Are Breaking Down or Getting Worse; and Step 6, Crisis Planning.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Fill in the Blank 17. _________________________ from mental health disorders and substance use disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to

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reach their full potential.

ANS: Recovery Recovery from mental health disorders and substance use disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Recovery is the restoration to a former or better state or condition.

KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance

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Chapter 22. Neurocognitive Disorders Multiple Choice 1. A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred?

A. Taking multiple medications may lead to adverse interactions or toxicity.

B. Age-related cognitive changes may lead to alterations in mental status.

C. Lack of rigorous exercise may lead to decreased cerebral blood flow.

D. Decreased social interaction may lead to profound isolation and psychosis.

ANS: A The nurse should identify that taking multiple medications may lead to adverse reactions or toxicity and put an older adult at risk for the development of delirium. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity 2. A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the clients safety?

A. His wife works from home in telecommunication.

B. The client has worked the night shift his entire career.

C. His wife has minimal family support.

D. The client smokes one pack of cigarettes per day.

ANS: D Forgetfulness is an early symptom of dementia that would alert the nurse to question the clients safety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease. The cause of vascular dementia is related to an interruption of blood flow to the brain.

High blood pressure and hypertension are significant factors in the etiology.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 3. A client diagnosed with neurocognitive disorder due to Alzheimers disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness?

A. Confabulation stage B. Early stage C. Middle stage D. Late stage ANS: D The nurse should recognize that this client is in the late stage of Alzheimers disease. The late stage is

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characterized by a severe cognitive decline.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 4. A client is in the late stage of Alzheimers disease. To address the clients symptoms, which nursing intervention should take priority?

A. Improve cognitive status by encouraging involvement in social activities.

B. Decrease social isolation by providing group therapies.

C. Promote dignity by providing comfort, safety, and self-care measures.

D. Facilitate communication by providing assistive devices.

ANS: C KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Basic Care and Comfort 5. A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition?

A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism ANS: C The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). In NCD, impairment is evident in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 6. A nursing instructor is teaching about donepezil (Aricept). A student asks, How does this work? Will this cure Alzheimers disease (AD)? Which is the appropriate instructor reply?

A. This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. B. This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.

C. This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. D. This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.

ANS: A

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The most appropriate response by the instructor is to explain that donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of AD. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 7. Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)?

A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity ANS: C The nurse should identify that attention and concentration are impaired in neurocognitive disorder and not in pseudodementia (depression).

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 8. At what time during a 24-hour period should a nurse expect clients with Alzheimers disease to exhibit more pronounced symptoms?

A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications ANS: C The nurse should determine that clients with Alzheimers disease exhibit more pronounced symptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the late afternoon and evening.

KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 9. A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate?

A. Schedule structured daily routines.

B. Minimize environmental lighting.

C. Organize a group activity to present reality.

D. Explain the consequences for aggressive behaviors.

ANS: A The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured

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routine will reduce frustration and thereby reduce verbal aggression.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimers disease. What should cause the nurse to question this diagnosis?

A. Neurocognitive disorder does not typically occur in African American clients.

B. The symptoms presented are more indicative of Parkinsonism.

C. Neurocognitive disorder does not develop suddenly.

D. There has been no T3 or T4 level evaluation ordered.

ANS: C The nurse should know that neurocognitive disorder (NCD) does not develop suddenly and should question this diagnosis. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed.

The disease is generally progressive and debilitating.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 11. A client diagnosed with neurocognitive disorder due to Alzheimers disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority?

A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the clients room with name and number D. Assist with bathing and toileting ANS: D The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 12. A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the clients behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation?

A. Consult the psychologist regarding behavior-modification techniques.

B. Medicate the client with prn antianxiety medications.

C. Assess environmental triggers and potential unmet needs.

D. Anticipate the behavior and restrain when pacing begins.

ANS: C The initial nursing action is to assess environmental triggers and potential unmet needs. Due to the cognitive

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decline experienced in a client diagnosed with neurocognitive disorder, communication skills may be limited.

The client may become disoriented and frustrated.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 13. A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this clients assessment data, which diagnosis would the nurse expect the physician to assign?

A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimers disease ANS: B The nurse should expect that this client would be diagnosed with vascular neurocognitive disorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abrupt onset. This disease often occurs in a fluctuating pattern of progression.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 14. An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe?

A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft) ANS: D The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the clients social functioning and concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptake inhibitor) antidepressant.

Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A client diagnosed with neurocognitive disorder due to Alzheimers disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis?

A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance ANS: C

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The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Reduction of Risk Potential 16. Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients diagnosed with amnesic disorders?

A. Neurocognitive disorders involve disorientation that develops suddenly, whereas amnestic disorders develop more slowly.

B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not.

C. Neurocognitive disorders include the symptom of confabulation, whereas amnestic disorders do not.

D. Both neurocognitive disorders and profound amnesia typically share the symptom of disorientation to place, time, and self.

ANS: B Neurocognitive disorders involve impairment of abstract thinking and judgment. Amnestic disorders are characterized by an inability to learn new information and to recall previously learned information, with no impairment in higher cortical functioning or personality change.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

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Chapter 23. Substance-Related and Addictive Disorders Multiple Choice 1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Reduction of Risk Potential 2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30minute period. Which is the best rationale for assessing this client for substance use disorder?

A. Narcotic pain medication is contraindicated for all clients with active substance-use problems.

B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.

C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction.

D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessens the clients response to another drug.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 3. On the first day of a clients alcohol detoxification, which nursing intervention should take priority?

A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.

B. Educate the client about the biopsychosocial consequences of alcohol abuse.

C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.

D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening

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effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which client statement indicates a knowledge deficit related to substance use?

A. Although its legal, alcohol is one of the most widely abused drugs in our society.

B. Tolerance to heroin develops quickly.

C. Flashbacks from LSD use may reoccur spontaneously.

D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.

ANS: D The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have potentially harmful effects. Cannabis is the second most widely abused drug in the United States.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance 5. A lonely, depressed divorce has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individuals situation?

A. The individual is experiencing psychological addiction.

B. The individual is experiencing physical addiction.

C. The individual is experiencing substance addiction.

D. The individual is experiencing social addiction.

ANS: A The nurse should use the term psychological addiction to best describe this clients situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?

A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent lifethreatening symptoms that occur because of the rebound reaction of the central nervous system.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:

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Physiological Integrity: Pharmacological and Parenteral Therapies 7. A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching?

A. After discharge, the client will immediately attend 90 AA meetings in 90 days.

B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.

C. After discharge, the client will incorporate family in AA attendance.

D. After discharge, the client will seek appropriate deterrent medications through AA. ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician?

A. Antecubital bruising B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential 9. Which client statement demonstrates positive progress toward recovery from a substance use disorder?

A. I have completed detox and therefore am in control of my drug use.

B. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings.

C. As a church deacon, my focus will now be on spiritual renewal.

D. Taking those pills got out of control. It cost me my job, marriage, and children.

ANS: D A client who takes responsibility for the consequences of substance use is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process, in which he or she accepts the fact that substance use causes problems.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention?

A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential 11. Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?

A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 12. A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect.

She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client?

A. Im not going to use heroin ever again. I know Ive got the willpower to do it this time.

B. I cannot control my use of heroin. Its stronger than I am.

C. Im going to get all my children back. They need their mother.

D. Once I deal with my childhood physical abuse, recovery should be easy.

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over

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the substance.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 13. A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. Which is the appropriate nursing response?

A. Why do you assume responsibility for his behaviors?

B. Codependency is a typical behavior of spouses of alcoholics.

C. Your husband needs to deal with the consequences of his drinking.

D. Do you understand what the term enabler means?

ANS: C The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?

A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin) ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 15. During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if my wife hadnt been nagging me all the time to get a job. She never did think that I was good enough for her.

How should a nurse interpret this statement?

A. The client is using denial by avoiding responsibility.

B. The client is using displacement by blaming his wife.

C. The client is using rationalization to excuse his alcohol dependence.

D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C

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The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder.

Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 16. A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

A. The client will identify one person to turn to for support.

B. The client will give up all old drinking buddies.

C. The client will be able to verbalize the effects of alcohol on the body.

D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 17. A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?

A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs.

Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 18. A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms?

A. Between 3 a.m. and 11 a.m.

B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3

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a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential 19. A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?

A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.

B. Sedative-hypnotics are expensive and have numerous side effects.

C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.

D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential 20. A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem?

A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess?

A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension ANS: A

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Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 22. A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse?

A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 23. A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral).

Which is the most appropriate reply by the nurse?

A. This medication will help you maintain your abstinence.

B. This medication will cause uncomfortable symptoms if you combine it with alcohol.

C. This medication will decrease the effect alcohol has on your body.

D. This medication will lower your risk of experiencing a complicated withdrawal.

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 24. A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication?

A. Only oral ingestion of alcohol will cause a reaction when taking this drug.

B. It is safe to drink beverages that have only 12% alcohol content.

C. This medication will decrease your cravings for alcohol.

D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug.

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last

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for as long as 2 weeks.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 25. Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?

A. Darken the room to reduce stimuli in order to prevent seizures.

B. Assess aggressive behaviors in order to intervene to prevent injury to self or others.

C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system.

D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 26. A client diagnosed with alcohol use disorder joins a community 12-step program and states, My life is unmanageable. How should the nurse interpret this clients statement?

A. The client is using minimization as an ego defense.

B. The client is ready to sign an Alcoholics Anonymous contract for sobriety.

C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous.

D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 27. In assessing a client with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention?

A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP) ANS: B If large doses of a central nervous system (CNS) depressant (such as Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

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28. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation ANS: C The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three yes answers strongly suggests a problem with alcohol.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 29. Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply.

A. I am easily manipulated and need to work on this prior to caring for these clients.

B. Because of my fathers alcoholism, I need to examine my attitude toward these clients.

C. Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights.

D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training.

E. I can fix clients diagnosed with substance use disorders as long as I truly care about them.

ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurses ability to establish therapeutic relationships with these clients. A nurse who adopts the attitude that he or she can fix another person may be struggling with codependency issues.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 30. A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? Select all that apply.

A. A diet rich in protein will promote hepatic healing.

B. This condition leads to a rise in serum ammonia, resulting in impaired mental functioning.

C. In this condition, blood accumulates in the abdominal cavity.

D. Neomycin and lactulose are used in the treatment of this condition.

E. This condition is caused by the inability of the liver to convert ammonia to urea.

ANS: A, C

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The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing or that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia by means of neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

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Chapter 24. Schizophrenia Spectrum and Other Psychotic Disorders Multiple Choice 1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?

A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors ANS: B The nurse should note escalating behaviors and intervene immediately to maintain this clients safety. Early intervention may prevent an aggressive response and keep the client and others safe.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse?

A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse, Where do the voices come from? Which is the appropriate nursing reply?

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts.

B. Your childs hallucinations are caused by medication interactions.

C. Your child has too little serotonin in the brain, causing delusions and hallucinations.

D. Your childs abnormal hormonal changes have precipitated auditory hallucinations.

ANS: A The nurse should explain that a chemical imbalance of the brain leads to altered thought processes.

Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

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4. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?

A. Tell him to stop discussing the voices.

B. Ignore what he is saying, while attempting to discover the underlying cause.

C. Focus on the feelings generated by the hallucinations and present reality.

D. Present objective evidence that the voices are not real.

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive special messages from certain sources, such as the television or radio? Which potential symptom of this disorder is the nurse assessing?

A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my shoes out of my room last night. Which is an appropriate charting entry to describe this clients statement?

A. The client is experiencing command hallucinations.

B. The client is expressing a neologism.

C. The client is experiencing a paranoia.

D. The client is verbalizing a word salad.

ANS: B The nurse should describe the clients statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity

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7. During an admission assessment, a nurse asks a client diagnosed with schizophrenia, Have you ever felt that certain objects or persons have control over your behavior? The nurse is assessing for which type of thought disruption?

A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the clients behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A client diagnosed with schizophrenia states, Cant you hear him? Its the devil. Hes telling me Im going to hell. Which is the most appropriate nursing reply?

A. Did you take your medicine this morning?

B. You are not going to hell. You are a good person.

C. Im sure the voices sound scary. I dont hear any voices speaking.

D. The devil only talks to people who are receptive to his influence.

ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 9. A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president.

Which nursing diagnosis should the nurse prioritize for this client?

A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury ANS: C The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

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10. Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

A. Provide neon lights and soft music.

B. Maintain continual eye contact throughout the interview.

C. Use therapeutic touch to increase trust and rapport.

D. Provide personal space to respect the clients boundaries.

ANS: D The most appropriate nursing intervention is to provide personal space to respect the clients boundaries.

Providing personal space may serve to reduce anxiety and thus reduce the clients risk for violence.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?

A. Establishing personal contact with family members.

B. Being reliable, honest, and consistent during interactions.

C. Sharing limited personal information.

D. Sitting close to the client to establish rapport.

ANS: B The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the clients needs and maintain a calm attitude when dealing with agitated behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. A client diagnosed with schizophrenia states, My psychiatrist is out to get me. Im sad that the voice is telling me to stop him. What symptom is the client exhibiting, and what is the nurses legal responsibility related to this symptom?

A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting ANS: C The nurse should determine that the client is exhibiting command hallucinations. The nurses legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.

KEY: Cognitive Level: Analysis | Integrated Processes: Communication and Documentation; Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 13. Which statement should indicate to a nurse that an individual is experiencing a delusion?

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A. Theres an alien growing in my liver.

B. I see my dead husband everywhere I go.

C. The IRS may audit my taxes.

D. Im not going to eat my food. It smells like brimstone.

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the persons intelligence or cultural background.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others.

Which medication should a nurse expect a physician to order to address this type of symptom?

A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms,

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and echolalia. Which statement correctly differentiates the clients positive and negative symptoms of schizophrenia?

A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia.

B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia.

C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia.

D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 17. A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment?

A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin) D. Tardive dyskinesia, treated by discontinuing antipsychotic medications ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions?

A. Neuroleptic malignant syndrome B. Tardive dyskinesia C. Acute dystonia D. Agranulocytosis ANS: A Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability.

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KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 19. A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the clients attending psychiatrist?

A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation ANS: C When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 20. An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, the nurse would most appropriately make which statement?

A. Make sure you concentrate on taking slow, deep, cleansing breaths.

B. Watch your diet and try to engage in some regular physical activity.

C. Rise slowly when you change position from lying to sitting or sitting to standing.

D. Wear sunscreen and try to avoid midday sun exposure.

ANS: C The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions.

Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.

KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential 21. A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 22. If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect?

A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considered as a treatment option. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity 23. During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of this assessment data, which antipsychotic medication would be contraindicated?

A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 24. A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize?

A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood ANS: B The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need:

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Psychosocial Integrity 25. A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the clients focus on delusional thinking?

A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion ANS: B The nurse should focus on the clients feelings rather than attempt to change the clients delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 26. A client states, I hear voices that tell me that I am evil. Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge?

A. The client will verbalize the reason the voices make derogatory statements.

B. The client will not hear auditory hallucinations.

C. The client will identify events that increase anxiety and illicit hallucinations.

D. The client will positively integrate the voices into the clients personality structure.

ANS: C It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 27. A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control.

Symptoms exhibited on admission included paranoia and hallucinations. The nurse should recognize which potential cause for the return of these symptoms?

A. The client has developed tolerance to the antipsychotic medication.

B. The client has not taken the medication with food.

C. The client has not taken the medication as prescribed.

D. The client has combined alcohol with the medication.

ANS: C Altered thinking can affect a clients insight into the necessity for taking antipsychotic medications consistently.

When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 28. Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply.

A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training ANS: A, B, D, E The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia.

Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 29. A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply.

A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

KEY: Cognitive Level: Comprehension | Integrated Process: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 30. Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply.

A. Apathy B. Social withdrawal C. Anhedonia

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Galactorrhea and gynecomastia are symptoms of prolactin elevation.

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Chapter 25. Depressive Disorders Multiple Choice 1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder?

A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia.

Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder?

A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 3. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis?

A. The client is disheveled and malodorous.

B. The client refuses to interact with others.

C. The client is unable to feel any pleasure.

D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder.

Which laboratory value would potentially rule out this diagnosis?

A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL ANS: A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the clients laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse.

According to learning theory, what is the cause of this clients symptoms?

A. Depression is a result of anger turned inward.

B. Depression is a result of abandonment.

C. Depression is a result of repeated failures.

D. Depression is a result of negative thinking.

ANS: C Learning theory describes a model of learned helplessness in which multiple life failures cause the client to abandon future attempts to succeed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder?

A. The attention during the assessment is beneficial in decreasing social isolation.

B. Depression is a symptom of several medical conditions.

C. Physical health complications are likely to arise from antidepressant therapy.

D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 7. A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents?

A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac) ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam?

A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder ANS: C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimers disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 9. A confused client has recently been prescribed sertraline (Zoloft). The clients spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause?

A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor add that to my medications?

Which is an appropriate nursing reply?

A. This combination of drugs can lead to delirium tremens.

B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.

C. Thats a good idea. There have been good results with the combination of these two drugs.

D. The only disadvantage would be the exorbitant cost of the MAOI. ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid?

A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching?

A. I cannot drink any alcohol with this medication.

B. It is going to take 2 to 3 weeks in order for me to begin to feel better.

C. This drug causes physical dependence, and I need to strictly follow doctors orders.

D. I cant take this medication with food. It needs to be taken on an empty stomach.

ANS: B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this clients plan of care?

A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation ANS: A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu?

A. Well go to the day room when you are ready for group.

B. Ill walk with you to the day room. Group is about to start.

C. It must be difficult for you to attend group when you feel so bad.

D. Let me tell you about the benefits of attending this group.

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 15. A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response?

A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine.

B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role.

C. Depression is a learned state of helplessness cause by ineffective parenting.

D. Depression is caused by intrapersonal conflict between the id and the ego.

ANS: B Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

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KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 16. What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)?

A. The clients understanding of the need for regular bloodwork B. The clients mood and affect score, according to the facilitys mood scale C. The clients cognitive ability to understand information about the medication D. The clients access to a support network willing to participate in treatment ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 17. A client diagnosed with major depressive disorder states, Ive been feeling down for 3 months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients affective symptoms?

A. Have you been diagnosed with any physical disorder within the last 3 months?

B. Have you ever felt this way before?

C. People who have mood changes often feel better when spring comes.

D. Help me understand what you mean when you say, feeling down?

ANS: D The nurse is using a clarifying statement in order to gather more details related to this clients mood.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, Im feeling a lot better, so you can stop watching me. I have taken up too much of your time already. Which is the best nursing reply?

A. I really appreciate your concern but I have been ordered to continue to watch you.

B. Because we are concerned about your safety, we will continue to observe you.

C. I am glad you are feeling better. The treatment team will consider your request.

D. I will forward you request to your psychiatrist because it is his decision.

ANS: B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

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19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client?

A. Teach about the effect of suicide on family dynamics.

B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock.

C. Encourage the client to spend a portion of each day interacting within the milieu.

D. Set realistic achievable goals to increase self-esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework?

A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory ANS: C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |Client Need: Psychosocial Integrity 21. Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder?

A. Its just a matter of time and I will be well.

B. If I ignore these feelings, they will go away.

C. I can fight these feelings and overcome this disorder.

D. Nothing will help me feel better.

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily.

The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority?

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A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis?

A. I am sad most of the time and Ive felt this way for the last several years.

B. I find myself preoccupied with death.

C. Sometimes I hear voices telling me to kill myself.

D. Im afraid to leave the house.

ANS: A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 24. A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness?

A. Encourage the client to bring into awareness underlying sources of guilt.

B. Teach the client that religious beliefs should be put into perspective throughout the life span.

C. Confront the client with the irrational nature of the belief system.

D. Assist the client to modify his or her belief system in order to improve coping skills.

ANS: A A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 25. A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client

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receiving which medication?

A. Tofranil B. Senequan C. Geodon D. Parnate ANS: D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 26. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess?

A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 27. A newly admitted client diagnosed with major depressive disorder states, I have never considered suicide.

Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply?

A. There is nothing to worry about. We will handle it together.

B. Bringing this up is a very positive action on your part.

C. We need to talk about the things you have to live for.

D. I think you should consider all your options prior to taking this action.

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response

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28. A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply.

A. Symptoms are causing significant interference with work, school, and social relationships.

B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating ANS: A, C, D Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week postmenses KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 29. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms?

Select all that apply.

A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the clients symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 30. A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply.

A. Ill have to let my surgeon know about this medication before I have my cholecystectomy.

B. Guess I will have to give up my glass of red wine with dinner.

C. Ill have to be very careful about reading food and medication labels.

D. Im going to miss my caffeinated coffee in the morning.

E. Ill be sure not to stop this medication abruptly.

ANS: A, B, C, E

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The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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Chapter 26. Bipolar and Related Disorders Multiple Choice 1. A highly agitated client paces the unit and states, I could buy and sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior?

A. Rates mood 8/10. Exhibiting looseness of association. Euphoric.

B. Mood euthymic. Exhibiting magical thinking. Restless.

C. Mood labile. Exhibiting delusions of reference. Hyperactive.

D. Agitated and pacing. Exhibiting grandiosity. Mood labile.

ANS: D The nurse should document that this clients behavior is Agitated and pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment 2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?

A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights ANS: B The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes?

Client Outcomes: 1. Maintains nutritional status.

2. Interacts appropriately with peers.

3. Remains free from injury.

4. Sleeps 6 to 8 hours a night.

A. 2, 1, 3, 4 B. 4, 1, 2, 3

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C. 3, 1, 4, 2 D. 1, 4, 2, 3 ANS: C The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients physical and safety needs.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment: Management of Care 4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft).

Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?

A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment ANS: A The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.

KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders?

A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil) ANS: B Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions the Zyprexa order. Which is the appropriate nursing reply?

A. Zyprexa in combination with Eskalith cures manic symptoms.

B. Zyprexa prevents extrapyramidal side effects.

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C. Zyprexa ensures a good nights sleep.

D. Zyprexa calms hyperactivity until the Eskalith takes effect.

ANS: D The nurse should explain to the clients spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 7. A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply?

A. Thats strange. Weight loss is the typical pattern.

B. What have you been eating? Weight gain is not usually associated with lithium.

C. Weight gain is a common but troubling side effect.

D. Weight gain occurs only during the first month of treatment with this drug.

ANS: C The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 8. A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?

A. This disorder is more prevalent in the lower socioeconomic groups.

B. This disorder is more prevalent in the higher socioeconomic groups.

C. This disorder is equally prevalent in all socioeconomic groups.

D. This disorders prevalence cannot be evaluated on the basis of socioeconomic groups.

ANS: B The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 9. A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

A. Symptoms indicate consumption of foods high in tyramine.

B. Symptoms indicate lithium carbonate discontinuation syndrome.

C. Symptoms indicate the development of lithium carbonate tolerance.

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D. Symptoms indicate lithium carbonate toxicity.

ANS: D The nurse should interpret that the clients symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 10. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?

A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool ANS: B The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order?

A. This dosage is within the recommended dosage range.

B. This dosage is lower than the recommended dosage range.

C. This dosage is more than twice the recommended dosage range.

D. This dosage is four times higher than the recommended dosage range.

ANS: C The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily.

KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?

A. Treatment is compromised when clients cant sleep.

B. Treatment is compromised when irritability interferes with social interactions.

C. Treatment is compromised when clients have no insight into their problems.

D. Treatment is compromised when clients choose not to take their medications.

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ANS: D The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications.

Symptoms of bipolar disorder will reemerge if medication is stopped.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week?

A. Provide client with high-calorie finger foods throughout the day.

B. Accompany client to cafeteria to encourage adequate dietary consumption.

C. Initiate total parenteral nutrition to meet dietary needs.

D. Teach the importance of a varied diet to meet nutritional needs.

ANS: A The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?

A. The client will accomplish activities of daily living independently by discharge.

B. The client will verbalize feelings during group sessions by discharge.

C. The client will remain safe throughout hospitalization.

D. The client will use problem-solving to cope adequately after discharge.

ANS: C A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be at risk for suicide.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 15. A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, You cant do this to me. Do you know who I am? Which is the priority nursing action in this situation?

A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation ANS: A

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During a manic episode the clients mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess?

A. The client expresses feeling blue most of the time.

B. The client has endured periods of elation and dysphoria lasting for more than 2 years.

C. The client fixates on hopelessness and thoughts of suicide continually.

D. The client has labile moods with periods of acute mania.

ANS: B The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 17. After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement?

A. I should expect to feel better in a couple of days.

B. Ill call my doctor immediately if I experience any diarrhea or ringing in my ears.

C. If I forget a dose, I can double the dose the next time I take this drug.

D. I need to restrict my intake of any food containing salt.

ANS: B The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level?

A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L ANS: B The therapeutic level of lithium carbonate is 1.0 to 1.5 mEq/L for acute mania and 0.6 to 1.2 mEq/L for maintenance therapy. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7

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mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated.

The nurse should assign which priority nursing diagnosis to this client?

A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night ANS: C Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 20. A client who has been diagnosed with bipolar I disorder states, God has taught me how to decode the Bible. A nurse should anticipate that which combination of medications would be ordered to address this clients symptoms?

A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal) ANS: A The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom?

A. I cant stop my sexual urges. They have led me to numerous affairs.

B. Im the worlds most perceptive attorney.

C. My wife is distraught about my overspending.

D. The FBI is out to get me.

ANS: B

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Grandiosity is defined as a belief that personal abilities are better than anyone elses. This client is experiencing delusions of grandeur, which are commonly experienced in mania.

KEY: Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Psychosocial Integrity 22. Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

A. I will limit my intake of fluids daily.

B. I will maintain normal salt intake.

C. I will take Lithobid on an empty stomach.

D. I will increase my caloric intake to prevent weight loss.

ANS: B A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change.

What should be the nurses initial intervention?

A. Ask the group to take a vote on alternative weekend events.

B. Remind the client to quiet down or leave the dayroom.

C. Assist the client to move to a calmer location.

D. Discuss with the client impulse control problems.

ANS: C During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurses initial action should focus on removing the client from the stimulating environment to a calmer location.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 24. A client diagnosed with bipolar disorder states, I hate oatmeal. Lets get everybody together to do exercises.

Im thirsty and Im burning up. Get out of my way; I have to see that guy. What should be the priority nursing action?

A. Assess the clients vital signs.

B. Offer to have the dietitian discuss food preferences.

C. Encourage the client to lead the exercise program in the community meeting.

D. Acknowledge the client briefly and then walk away.

ANS: A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-

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occurring physical problems could be masked by hyperactive, manic, or both behaviors. The clients statement of Im thirsty and Im burning up could be a symptom of either infection or dehydration and must be assessed.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 25. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess?

A. Pacing B. Flight of ideas C. Lability of mood D. Irritability ANS: B Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom dcor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate?

A. Rooms should contain extra-large windows with views of the street.

B. Rooms should contain brightly colored walls with printed drapes.

C. Rooms should be painted deep colors and located close to the nurses station.

D. Rooms should be painted with neutral colors and contain pale-colored accessories.

ANS: D Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the clients environment (low lighting, few people, simple dcor, low noise levels). Anxiety levels rise in a stimulating environment.

Neutral colors and pale accessories are most appropriate for a client experiencing mania.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 27. A clients spouse asks, What evidence supports the possibility of genetic transmission of bipolar disorder?

Which is the best nursing reply?

A. Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors.

B. Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder.

C. Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress.

D. More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds.

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ANS: B Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client?

A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers ANS: A Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 29. Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? Select all that apply.

A. Avoid excessive use of beverages containing caffeine.

B. Maintain a consistent sodium intake.

C. Consume at least 2,500 to 3,000 mL of fluid per day.

D. Restrict sodium content.

E. Restrict fluids to 1,500 mL per day.

ANS: A, B, C The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 30. Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply.

A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms.

B. Children are naturally active, energetic, and spontaneous.

C. Neurotransmitter levels vary considerably in accordance with age.

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D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.

E. Genetic predisposition is not a reliable diagnostic determinant.

ANS: A, B It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

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Chapter 27. Anxiety, Obsessive-Compulsive, and Related Disorders Multiple Choice 1. A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred?

A. These clients do not recognize that their fear is excessive, and they rarely seek treatment.

B. These clients have overwhelming symptoms of panic when exposed to the phobic stimulus.

C. These clients experience symptoms that mirror a cerebrovascular accident (CVA).

D. These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.

ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 2. A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified?

A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia, which is a natural environment type of phobia. Natural environmenttype phobias are fears about objects or situations that occur in the natural environment, such as a fear of heights or storms.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)?

A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications.

B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not.

C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.

D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

ANS: C

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Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 4. How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?

A. GAD is acute in nature, and panic disorder is chronic.

B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.

C. Hyperventilation is a common symptom in GAD and rare in panic disorder.

D. Depersonalization is commonly seen in panic disorder and absent in GAD. ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?

A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon) ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear?

A. Your spouse may be unable to resolve internal conflicts, which result in projected anxiety.

B. Your spouse may be experiencing a distorted and unrealistic appraisal of the situation.

C. Your spouse may have a genetic predisposition to overreacting to potential danger.

D. Your spouse may have high levels of brain chemicals that may distort thinking.

ANS: B

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The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. Arthur, who is diagnosed with obsessive-compulsive disorder, reports to the nurse that he cant stop thinking about all the potentially life threatening germs in the environment. What is the most accurate way for the nurse to document this symptom?

A. Patient is expressing an obsession with germs.

B. Patient is manifesting compulsive thinking.

C. Patient is expressing delusional thinking about germs.

D. Patient is manifesting arachnophobia of germs.

ANS: A Obsessions are unwanted, intrusive, repetitive thoughts. Compulsions are unwanted, repetitive behavior patterns in response to obsessive thoughts that are efforts to reduce anxiety.

KEY: Cognitive Level: Analysis | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity 8. A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of panic anxiety ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be panic anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 9. A client diagnosed with panic disorder states, When an attack happens, I feel like I am going to die. Which is the most appropriate nursing reply?

A. I know its frightening, but try to remind yourself that this will only last a short time.

B. Death from a panic attack happens so infrequently that there is no need to worry.

C. Most people who experience panic attacks have feelings of impending doom.

D. Tell me why you think you are going to die every time you have a panic attack.

ANS: A The most appropriate nursing reply to the clients concerns is to empathize with the client and provide

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encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?

A. Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.

B. Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.

C. Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.

D. Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.

ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, Should I seek psychiatric help for my mother? Which is an appropriate nursing reply?

A. My mother also worries unnecessarily. I think it is part of the aging process.

B. Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.

C. From what you have told me, you should get her to a psychiatrist as soon as possible.

D. Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.

ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 12. A client is experiencing a severe panic attack. Which nursing intervention would meet this clients immediate need?

A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar) ANS: C

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The nurse can meet this clients immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life, and the presence of a trusted individual provides assurance of personal safety.

KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Psychosocial Integrity 13. A college student is unable to take a final examination because of severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?

A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the clients healthy coping skills and reduce anxiety.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 14. A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client?

A. Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge.

B. Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.

C. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.

D. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.

ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety-provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 15. A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

A. The client will refrain from ritualistic behaviors during daylight hours.

B. The client will wake early enough to complete rituals prior to breakfast.

C. The client will participate in three unit activities by day 3.

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D. The client will substitute a productive activity for rituals by day 1.

ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 16. A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?

A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.

B. I wont stop taking this medication abruptly, because there could be serious complications.

C. I will not drink alcohol while taking this medication.

D. I wont take extra doses of this drug because I can become addicted.

ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine.

The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate.

Which defense mechanism should the nurse identify?

A. Sublimation B. Dissociation C. Rationalization D. Intellectualization ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this clients problem?

A. Distract the client with other activities whenever ritual behaviors begin.

B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.

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C. Lock the room to discourage ritualistic behavior.

D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior.

If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors.

Attempting to distract the client, seeking medication increase, and locking the clients room are not appropriate interventions because they do not help the client recognize anxiety triggers.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 19. A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg daily, for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate?

A. High doses of tricyclic medications will be required for effective treatment of OCD. B. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD. C. The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia.

D. The dosage of Luvox is outside the therapeutic range and needs to be questioned.

ANS: B The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 20. A client presents in the emergency department with complaints of overwhelming anxiety. Which of the following is a priority for the nurse to assess?

A. Risk for suicide B. Cardiac status C. Current stressors D. Substance use history ANS: B Although all of the listed aspects of assessment are important, the priority is to evaluate cardiac status since a person having an MI, CHF, or mitral valve prolapse can present with symptoms of anxiety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment: Management of Care 21. A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?

A. History of alcohol dependence B. History of personality disorder

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C. History of schizophrenia D. History of hypertension ANS: A The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 22. Warrens college roommate actively resists going out with friends whenever they invite him. He says he cant stand to be around other people and confides to Warren They wouldnt like me anyway. Which disorder is Warrens roommate likely suffering from?

A. Agoraphobia B. Mysophobia C. Social anxiety disorder (social phobia) D. Panic disorder ANS: C Social anxiety disorder is an excessive fear of social situations R/T fear that one might do something embarrassing or be evaluated negatively by others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 23. A client has the following symptoms: preoccupation with imagined defect, verbalizations that are out of proportion to actual physical abnormalities, and numerous visits to plastic surgeons to seek relief. Which nursing diagnosis would best describe the problems evidenced by these symptoms?

A. Ineffective coping B. Disturbed body image C. Complicated grieving D. Panic anxiety ANS: B The symptoms presented describe the DSM-5 diagnosis of body dysmorphic disorder, and the related nursing diagnosis is disturbed body image.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 24. How should a nurse best describe the major maladaptive client response to panic disorder?

A. Clients overuse medical care because of physical symptoms.

B. Clients use illegal drugs to ease symptoms.

C. Clients perceive having no control over life situations.

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D. Clients develop compulsions to deal with anxiety.

ANS: C The major maladaptive client response to panic disorder is the perception of having no control over life situations, which leads to nonparticipation in decision making and doubts regarding role performance.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 25. A client diagnosed with generalized anxiety states, I know the best thing for me to do now is to just forget my worries. How should the nurse evaluate this statement?

A. The client is developing insight.

B. The clients coping skills are improving.

C. The client has a distorted perception of problem resolution.

D. The client is meeting outcomes and moving toward discharge.

ANS: C This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose?

A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions ANS: B Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system, leading to respiratory arrest and death.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Multiple Response 27. A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? Select all that apply.

A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia

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E. Irritability ANS: A, D, E The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability.

GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 28. A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? Select all that apply.

A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy ANS: B, C The nurse should explain to the client that systematic desensitization and imploding are the most commonly used behavioral therapies in the treatment of phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 29. A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this clients symptoms? Select all that apply.

A. Encourage the client to recognize the signs of escalating anxiety.

B. Encourage the client to avoid any situation that causes stress.

C. Encourage the client to employ newly learned relaxation techniques.

D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety.

E. Encourage the client to avoid caffeinated products.

ANS: A, C, D, E Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 30. A client who has been diagnosed with a phobic disorder asks the nurse if there are any medications that would be beneficial in treating phobic disorders. Which of the following would be accurate responses by the nurse? Select all that apply.

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A. Some antianxiety agents have been successful in treating social phobias.

B. Some antidepressant agents have been successful in diminishing symptoms of agoraphobia and social anxiety disorder (social phobia).

C. Specific phobias are generally not treated with medication unless accompanied by panic attacks.

D. Beta-blockers have been used successfully to treat phobic responses to public performance.

ANS: A, B, C, D All of the listed pharmacological treatments are evidence-based treatments for phobic disorders.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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Chapter 28: Trauma and Stressor-Related Disorders Multiple Response 1. A mother brings her son to the Emergency Department and tells the nurse that her son must have PTSD, because 2 days ago he witnessed a car accident in which there were fatalities. She is convinced that her son has PTSD because he has been crying when he talks about the incident. She believes that boys are at greater risk for PTSD because they dont typically cry. She read on the internet that PTSD can have dangerous consequences, so she wants her son to get some medication to cure the PTSD before it gets too bad. Which of these statements by the nurse would accurately correct this mothers misunderstanding about PTSD? Select all that apply.

A. There are no long-term or dangerous consequences from PTSD. B. Women appear to be at greater risk of this disorder than men.

C. Medications have been found to be effective in treating symptoms of depression or anxiety but do not represent a cure for the disorder.

D. Fewer than 10% of trauma victims develop PTSD. ANS: B, C, D Items B, C, and D are evidence-based pieces of information. Item A is incorrect since, in fact, dangerous consequences of unmanaged PTSD may include depression and/or suicide.

KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 2. A patient is admitted to the community mental health center for outpatient therapy with a diagnosis of Adjustment Disorder. Which of the following subjective statements by the patient support this diagnosis?

Select all that apply.

A. I was divorced 3 months ago and I cant seem to cope.

B. I was a victim of date rape 15 years ago when I was in college.

C. My partner came home last week and told me he just didnt love me anymore.

D. I failed one of my classes last month and I cant get motivated to register for my next semester.

ANS: A, C, D A diagnosis of Adjustment Disorder is appropriate when the stressors are related to relational conflict, where there are significant emotional or behavioral symptoms, and when the response occurs within 3 months after the onset of the stressor (and persists no longer than 6 months). Item B would be more aptly described as a traumatic event.

KEY: Cognitive Level: Evaluation | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. A military veteran is being assessed for outpatient therapy after he reports having problems at home and at work. Which of the symptoms that he describes are commonly associated with PTSD? Select all that apply.

A. Ive been drinking and smoking pot daily.

B. Ive been having trouble sleeping and I think Ive been having nightmares but I cant remember them.

C. I slapped my wife when she was trying to hug me.

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D. Ive been having intense pain in the leg where I sustained a combat wound.

ANS: A, B, C Common symptoms associated with PTSD include substance abuse, sleep disturbances, nightmares, and aggression. Whereas the combat exposure and wounding could be described as traumas, the patients complaint of pain requires further physical assessment rather than assuming this symptom is related to PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 4. A patients wife reports to the nurse that she was told her husbands PTSD may be related to cognitive problems. She is asking the nurse to explain what that means. Which of the following are accurate statements about the cognitive theory as it applies to PTSD? Select all that apply.

A. People are vulnerable to trauma-related disorders when their fundamental beliefs are invalidated.

B. Cognitive theory addresses the importance of how people think (or cognitively appraise) events.

C. Dementia is a common symptom of PTSD. D. Amnesia is the biggest cognitive problem in PTSD and is the primary cause of trauma-related disorders.

ANS: A, B Both A and B address aspects of cognitive theory and its relevance in PTSD. Dementia includes cognitive symptoms but is not a symptom of PTSD. Amnesia does not cause PTSD but is a symptom of PTSD. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 5. A nurse who works on an inpatient psychiatric unit is working on developing a treatment plan for a patient admitted with PTSD. The patient, a military veteran, reports that sometimes he thinks he sees bombs exploding and the enemy rushing toward him. He has had aggressive outbursts and was hospitalized after assaulting a coworker during one of these episodes. Which of these interventions by the nurse are evidence-based responses? Select all that apply.

A. Collaborate with the patient about how he would like staff to respond when he has episodes of reexperiencing traumatic events.

B. Tell the patient it is not appropriate to hit other patients or staff and if that occurs he will have to be discharged from the hospital.

C. Contact the doctor and recommend that the patient be ordered an antipsychotic medication.

D. Refer the patient to a support group with other military veterans.

ANS: A, D Collaborating with the patient demonstrates an environment of mutual respect and is helpful in establishing a trusting relationship. Both of these are identified as essential in effective treatment of PTSD. Evidence also supports that a group with other people who have experienced similar traumas is helpful in reducing the sense of isolation that some people with PTSD experience. Items B and C are incorrect since they both reflect an inaccurate understanding of the dynamics of PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. A patient admitted to the hospital with PTSD is ordered the following medications. Which of these medications has a direct use in treating symptoms that are common in PTSD? Select all that apply.

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A. Alprazolam B. Propanolol C. Colace D. Dulcolax ANS: A, B Alprazolam is an antianxiety agent and anxiety symptoms are common in PTSD. Propanolol is an antihypertensive medication and evidence has demonstrated its effectiveness in treating symptoms of PTSD, including nightmares, intrusive recollections, and insomnia. The last two medications are used to treat constipation, and this symptom is not directly related to PTSD. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 7. A patient who is being seen in the community mental health center for PTSD is being considered for EMDR (Eye Movement Desensitization and Reprocessing) therapy. The nurse is being asked to conduct an assessment to validate the patients appropriateness for this treatment. Which of the following pieces of data, collected by the nurse, are most important to document when determining appropriateness for treatment with EMDR? Select all that apply.

A. The patient has a history of a seizure disorder.

B. The patient has a history of ECT. C. The patient reports suicidal ideation with a plan.

D. The patient has been using alcohol in increasing quantities over the last 3 months.

ANS: A, C, D Items A, C, and D are all factors that would contraindicate the use of EMDR. A history of ECT is not directly relevant in determining appropriateness for EMDR. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Documentation | Client Need: Safe and Effective Care Environment 8. Joe, a patient being treated for PTSD, tells the nurse that his therapist is recommending cognitive therapy.

He asks the nurse how thats supposed to help his nightmares. Which of these responses by the nurse provides accurate information about the benefits of this type of therapy? Select all that apply.

A. The nightmares may be related to troubling thoughts and feelings; cognitive therapy will help you explore and modify those thoughts and feelings.

B. It is designed to help you cope with anxiety, anger, and other feelings that may be related to your symptoms.

C. It is designed to repeatedly expose you to the trauma you experienced so you can regain a sense of safety.

D. Once you learn to repress these troubling feelings, the nightmares should cease.

ANS: A, B Both A and B are desired outcomes in cognitive therapy. Item C more aptly describes prolonged exposure therapy. D is incorrect because exploration and awareness (rather than repression) are fundamental to cognitive therapy.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health

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Promotion and Maintenance 9. Joshua recently moved into a dormitory to begin his freshman year in college. He was reprimanded by the dormitory supervisor for not properly disposing of food items and responded by throwing all of his belongings from a second story window while shouting obscenities. The campus police escorted him to campus health services, where he was diagnosed with an Adjustment Disorder with Disturbance of Conduct. Which of the following items in Joshuas history predispose him to this disorder? Select all that apply.

A. Joshua reports that he doesnt have any friends in the dormitory.

B. Joshuas family currently lives out of the country and are often difficult to reach.

C. Joshua was notified the same day that he would have to withdraw from one of his classes because he didnt have the prerequisite credits needed to register for the class.

D. Joshua has a higher than average GPA and is a member of The National Honor Society.

ANS: A, B, C Items A and B may suggest lack of available support systems, which is identified as a predisposing factor for Adjustment Disorders. Item C presents evidence of another stressor occurring in proximity to the reprimand from the dormitory supervisor, which may also predispose to the development of an Adjustment Disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity Multiple Choice 10. Jane presents in the Emergency Department with a friend, who reports that Jane has been sitting in her apartment staring off into space and doesnt seem interested in doing anything. During the assessment Jane reveals, with little emotion, that she was raped 4 months ago. Which of these is the most appropriate interpretation of Janes lack of emotion?

A. Jane is probably hearing voices telling her to be emotionless.

B. Jane is experiencing numbing of emotional response, which is a common symptom of PTSD. C. Jane is trying to be secretive, and lying is a common symptom in PTSD. D. Jane is currently re-experiencing the traumatic event and is having a dissociative episode.

ANS: B General numbing of emotional response is a common symptom of PTSD. Items A and D are not the most appropriate interpretations because the data are inadequate to make that inference. Item C is incorrect; lying is not a common symptom in PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. Studies have suggested that re-experiencing a traumatic event can become an addiction of sorts. The evidence suggests that the reason for this is: A. People with PTSD often have addictive personalities.

B. Perpetuating the traumatic experience yields secondary gains.

C. The re-experiencing of trauma enhances production of endogenous opioid peptides.

D. People with PTSD often have concurrent substance abuse issues.

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ANS: C Hollander and Simeon (2008) report on studies suggesting that the release of endogenous opioid peptides can produce an addiction to the trauma. There is no evidence suggesting that addictive personality traits are responsible for chronicity in PTSD symptoms. Items B and D are possible outcomes in any individual with PTSD, but neither has been correlated to an addiction to re-experiencing trauma.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 12. Sandy, a rape survivor, is being treated for PTSD. Which of these statements are good indications that Sally is beginning to recover from PTSD? A. I still have nightmares every night, but I dont always remember them anymore.

B. Im not drinking as much alcohol as I had been over the last several months.

C. This traumatic event immobilized me for awhile, but I have found imagery helpful in reducing my anxiety.

D. All of the above.

ANS: C Item C demonstrates evidence of awareness of the impact the trauma had on Sandys life and demonstrates evidence of effective coping skills. Item A indicates continued presence of symptoms and possibly amnesia.

Although item B may be evidence of a positive coping strategy, evaluation of recovery from PTSD must also include assessment for less symptoms such as nightmares and flashbacks.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 13. A military vet who recently returned from active duty in a Middle Eastern country and suffers from PTSD states he will not allow the lab tech, who is Iranian, to draw his blood. The patient states Hell probably use a contaminated needle on me. Which of these is the most appropriate response by the nurse?

A. Let me see if I can arrange for a different technician to draw your blood.

B. Let me help you overcome your cultural bias by letting him draw your blood.

C. There is no other technician, so youre just going to have to let him draw your blood.

D. I dont think the technician is really Middle Eastern.

ANS: A Item A demonstrates acceptance of the patient and attempts to create a less threatening situation for the patient.

Item B makes an unsubstantiated assumption about the patients biases. Item C will not contribute to the patients sense of control, and sense of comfort and control is important in managing symptoms of PTSD. Item D minimizes the patients concerns rather than responding empathically to them.

KEY: Cognitive Level: Application | Integrated Processes: Caring | Client Need: Psychosocial Integrity 14. Which of these statements by the patient are indications of complicated grieving?

A. I feel like I should have been the one to die in that hurricane.

B. Last year, several of my coworkers died in a hurricane and I still cant go back to work.

C. Ive been having incapacitating migraines ever since the memorial services.

D. All of the above

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ANS: D Item A indicates survivor guilt, and items B and C are both indications that the trauma has contributed to functional impairment. All three are symptoms of complicated grieving.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. A patient being treated for symptoms of PTSD following a shooting incident at a local elementary school reports I feel like theres no reason to go on living when so many others died. Which of these is the most appropriate response by the nurse at this juncture?

A. Youve got lots of reasons to go on living B. Are you having thoughts of hurting or killing yourself?

C. Youre just experiencing survivor guilt.

D. There must be something that gives you hope.

ANS: B This patient is expressing hopelessness, and it is a priority to assess for suicide ideation in these circumstances.

Items A and D minimize the patients experience of feeling hopelessness. Item C may be a useful strategy to encourage the patient that this is a common experience of trauma survivors, but the immediate priority is determining patient safety.

KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity 16. Major Smith, who is being treated for PTSD symptoms following a course of military duty, reports, I think I was in denial about even having PTSD. I thought I was just having trouble sleeping. Which of these is an accurate evaluation of the patients comments?

A. The patient is still in denial and unable to recognize that he is having flashbacks rather than insomnia.

B. The patient is beginning to recognize stages of grieving and reevaluating his symptoms.

C. The patient is beginning to recognize that he may be at risk for suicide.

D. The patient is trying to avoid discussing symptoms of PTSD. ANS: B The patient is expressing recognition that he was in denial, which is a stage of grieving. It is not uncommon for people to recognize that they are having troubling symptoms but not immediately recognize this as PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 17. Brandy is an 18-year-old being treated in the Community Mental Health Clinic for an adjustment disorder after receiving news of her parents impending divorce. While talking about her feelings she becomes angry and starts shouting and crying. She screams, I wish they would both die! Which of these is the most appropriate response by the nurse at this point?

A. Contact the parents and the police to report that Brandy is expressing homicidal ideation.

B. Encourage Brandy to talk more about her anger.

C. Instruct Brandy that its okay to cry but that it is not acceptable to talk that way about her parents.

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D. Assess Brandy for suicidal ideation.

ANS: B It is important in treating patients with adjustment disorders to allow them to express anger. Item C discourages the patient from expressing anger. Items A and D would be premature, since there is inadequate evidence to warrant those responses.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Ordered Response 18. Samuel, a 19-year-old high school student, has been admitted to the psychiatric unit with a diagnosis of adjustment disorder with disturbance of conduct. He assaulted a teacher when he was told he was receiving detentions for a pattern of tardiness. The nurse, while completing rounds, finds the patient in his room crying, and one of his wrists is bleeding from a self-inflicted cut made by a piece of metal from an unknown source.

Prioritize each of the following nursing interventions from 1 to 5, with 1 being the highest priority. ___ A. Check the patients vital signs. ___ B. Assess the wound site. ___ C. Contact the parents. ___ D. Discuss with Samuel what precipitated this event. ___ E. Cleanse and treat the wound site to prevent infection.

ANS: A: 3 B: 1 C: 5 D: 4 E: 2 The first priority is assessment (Item B), followed by providing care to meet physical and safety needs (Items E and A). The next priority is responding to the patients emotional needs (Item D), and finally, contacting the patients parents (Item C) in accordance with standards for confidentiality of medical information.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Management of Care Fill in the Blank 19. According to NANDA (2012), a disorder that occurs after the death of a significant other or any loss perceived as significant to the individual, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment, is referred to as________________________.

ANS: Complicated grieving A grieving process that does not follow normative expectations may include fixation at a particular stage of grieving, psychosomatic symptoms, and/or impairment in occupational, social, intellectual, or emotional function.

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KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 20. Joe, who recently lost both parents in a tragic automobile accident, has been diagnosed with an adjustment disorder after he struck a friend who told him he needed to get his feelings out. The stage of grieving that Joe is struggling with is ___________________.

ANS: Anger The stages of grieving include denial, anger, bargaining, depression, and resolution. Joe is expressing anger but in a way that is impairing his relationships with others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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Chapter 29. Somatic Symptom and Dissociative Disorders Multiple Choice 1. A client diagnosed with somatic symptom disorder is most likely to exhibit which personality disorder characteristics?

A. Uses splitting and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange ANS: C It has been suggested that in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These features include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself. Somatic symptom disorder is characterized by the expression of multiple somatic complaints associated with psychosocial distress and without medical basis.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. A nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should a nurse expect to assess?

A. Disproportionate and persistent thoughts about the seriousness of ones symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms ANS: A The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with somatic symptom disorder?

A. The client will admit to fabricating physical symptoms to gain benefits by day 3.

B. The client will list three potential adaptive coping strategies to deal with stress by day 2.

C. The client will comply with medical treatments for physical symptoms by day 3.

D. The client will openly discuss physical symptoms with staff by day 4.

ANS: B The nurse should determine that an appropriate outcome for a client diagnosed with somatic symptom disorder

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would be for the client to list three potential adaptive coping strategies to deal with stress by day 2. Because the symptoms of somatic symptom disorder are associated with psychosocial distress, increasing coping skills may help the client reduce symptoms.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 4. Carly has been diagnosed with somatic symptom disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client?

A. The family agrees that Carly began having physical symptoms after she lost her job.

B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor.

C. Carlys mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating.

D. Carly states she noticed feeling hotter than usual the last time she had a headache.

ANS: C It is important for the nurse to identify gains that the symptoms might be providing for the client, since these can reinforce illness behavior. Having family attend to the patient when she is symptomatic could reinforce increased dependency and attention needs.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred?

A. Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness.

B. When their physical symptoms relieve them from stressful situations, their amnesia is reinforced.

C. People with dissociative disorders typically have strong egos.

D. There is clear and convincing evidence of a familial predisposition to this disorder.

ANS: A The nurse should understand that from a psychoanalytical perspective, dissociation occurs because of repression of painful information or experiences.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 6. An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?

A. Encourage exploration of sexual abuse B. Encourage guided imagery C. Establish trust and rapport D. Administer antianxiety medications

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ANS: C The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with dissociative identity disorder. DID was formerly called multiple personality disorder. Each personality views itself as a separate entity and must be treated as such to establish rapport. Trust is the basis of every therapeutic relationship.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function?

A. It is a means to attain secondary gain.

B. It is a means to explore feelings of excessive and inappropriate guilt.

C. It serves to isolate painful events so that the primary self is protected.

D. It serves to establish personality boundaries and limit inappropriate impulses.

ANS: C The nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A client is diagnosed with dissociative identity disorder (DID). What is the primary goal of therapy for this client?

A. To recover memories and improve thinking patterns B. To prevent social isolation C. To decrease anxiety and need for secondary gain D. To collaborate among subpersonalities to improve functioning ANS: D The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among subpersonalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the clients ability to function appropriately and achieve optimal personal potential.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Planning | Client Need: Psychosocial Integrity 9. Which of the following statements accurately describes dissociative fugue?

A. Dissociative fugue is not precipitated by stressful events.

B. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of ones past.

C. Dissociative amnesia and dissociative fugue are completely different types of disorders.

D. Dissociative fugue is characterized by a sense of observing oneself from outside the body.

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ANS: B Dissociative fugue is characterized by unexpected travel or bewildered wandering, and amnesia for all or part of ones past. Dissociative fugue is a subtype of dissociative amnesia.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. Which should the nurse recognize as an example of localized amnesia?

A. A client cannot relate any lifetime memories, including personal identity.

B. A client can relate family memories but has no recollection of a particular brother.

C. A client cannot remember events surrounding a fatal car accident.

D. A client whose home was destroyed by a tornado only remembers waking up in the hospital.

ANS: C An individual with localized amnesia is unable to recall all incidents associated with a stressful event.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?

A. Deal with physical symptoms in a detached manner.

B. Challenge the validity of physical symptoms.

C. Meet dependency needs until the physical limitations subside.

D. Encourage a discussion of feelings about the lower-extremity problem.

ANS: A The nurse should assist the client in dealing with physical symptoms in a detached manner to avoid reinforcing the symptoms by providing secondary gains. This is an example of a conversion disorder in which symptoms affect voluntary motor or sensory functioning. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. The family of a client diagnosed with conversion disorder asks the nurse, Will his paralysis ever go away?

Which of these responses by the nurse is evidence-based?

A. Most symptoms of conversion disorder resolve within a few weeks.

B. Typically people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives.

C. The only people who recover are those that develop conversion disorder symptoms without a precipitating stressful event.

D. Technically, he could walk now since he is intentionally feigning paralysis.

ANS: A

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The evidence supports that most conversion disorder symptoms resolve within a few weeks, and about 20% will have a relapse within 1 year.

KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Health Promotion and Maintenance Multiple Response 13. A client is diagnosed with illness anxiety disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply.

A. Obsessive-compulsive traits B. Pseudocyesis C. Disabling fear of having a serious illness D. Multiple pronounced physical symptoms E. Depression ANS: A, C, E Illness anxiety disorder involves a preoccupation with and fear of having or acquiring a serious disease.

Somatic symptoms are either absent or mild in intensity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? Select all that apply.

A. Can you tell me your name and where you live?

B. Have you ever traveled suddenly or unexpectedly away from home?

C. Have you recently experienced any traumatic event?

D. Have you ever felt detached from your environment?

E. Have you had any history of memory problems?

ANS: A, C, E An individual who has generalized amnesia has amnesia for his or her identity and total life history. The first question assesses orientation to identity. Items C and D assess for awareness of current issues and historical issues, respectively. Affirmative descriptions of either of these issues would rule out generalized amnesia.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. Which of the following somatic symptom and dissociative disorders are identified with known effective pharmacological treatments for that disorder? Select all that apply.

A. Antidepressants have been used effectively in treating pain associated with somatic symptom disorder.

B. Lithium has been effective in treating illness anxiety disorder.

C. Muscle relaxants have been effective in resolving conversion disorder symptoms.

D. The antidepressant clomipramine (Anafranil) has shown promise in treating depersonalization-derealization

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disorder.

ANS: A, D The nurse should recognize that psychological therapies are central treatment modalities for these disorders, although evidence exists that for specific issues (as those identified in items A and C), psychopharmacological agents have demonstrated effectiveness.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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Chapter 30. Issues Related to Human Sexuality and Gender Dysphoria Multiple Choice 1. A 52-year-old client states, My husband is upset because I dont enjoy sex as much as I used to. Which priority client data should a nurse initially collect?

A. History of hysterectomy B. Date of last menstrual cycle C. Use of birth control methods D. History of thought disorder ANS: B The nurse should assess the clients last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms, including a decrease in biological drives and sexual activity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 2. In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client?

A. Self-assess personal attitudes toward homosexuality B. Review clients possible childhood sexual abuse history C. Encourage discussion of aversion to heterosexual relationships D. Explore clients family history of homosexuality ANS: A The nurse should initially self-assess personal attitudes toward bisexuality. The nurse must be able to recognize the potential for negative feelings compromising client care. Unconditional acceptance of each individual is an essential component of compassionate nursing.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection.

He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis should be prioritized for this client?

A. Risk for situational low self-esteem AEB inability to achieve an erection B. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm C. Social isolation R/T low self-esteem AEB refusing to engage in dating activities D. Disturbed body image R/T penile flaccidity AEB client statements ANS: B On the basis of the clients symptoms, the nurse should prioritize the nursing diagnosis of sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the clients mood and level of energy because depression and fatigue can decrease desire for participation in sexual activity.

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KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 4. A nurse is assessing a client diagnosed with pedophilic disorder. What would differentiate this sexual disorder from a sexual dysfunction?

A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response.

B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response.

C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders.

D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

ANS: B The nurse should identify that pedophilic disorder is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Sexual dysfunction involves impairment in normal sexual response. Pedophilic disorder involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurses first priority?

A. Contact the clients psychiatrist.

B. Avoid addressing her attention-seeking behavior.

C. Lead the client back to her room and assist her to choose appropriate clothing.

D. Restrict client to room until visiting hours are over.

ANS: C The most appropriate intervention by the nurse is to lead the client back to her room and assist her to choose appropriate clothing. The client could be exhibiting signs of exhibitionistic disorder, which is characterized by urges to expose oneself to unsuspecting strangers.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. A nurse is working with a client diagnosed with pedophilic disorder. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization?

A. The client will verbalize an understanding of the importance of follow-up care.

B. The client will implement several relapse-prevention strategies.

C. The client will identify triggers that lead to inappropriate behaviors.

D. The client will attend aversion therapy groups.

ANS: C

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During the first week of hospitalization, identifying triggers that lead to inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilic disorder. Pedophilic disorder involves intense sexual urges, behaviors, or fantasies involving sexual activity with a prepubescent child.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 7. When planning care for a client diagnosed with female sexual arousal disorder, what should a nurse document as an expected outcome of sensate focus exercises?

A. To initiate immediate orgasm B. To reduce anxiety by eliminating physical touch C. To focus on touching breasts and genitals D. To reduce goal-oriented demands of intercourse ANS: D The expected outcome of sensate focus exercises is to reduce goal-oriented demands of intercourse. Sensate focus exercises consist of touching and being touched by another with attention focused on the physical sensations encountered. Erotic contact is gradually increased, leading to the possibility of sexual intercourse.

The reduction in demands reduces performance pressures and anxiety associated with possible failure.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 8. A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement?

A. A thorough physical to include gynecological examination B. Referral to a sex therapist C. Assessment of sexual history and previous satisfaction with sexual relationships D. Referral to the recreational therapist for relaxation therapy ANS: A The nurse should expect the physician to implement a thorough physical to include a gynecological examination to assess for any physiological causes of the clients symptoms. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 9. A client is diagnosed with hypoactive sexual desire disorder. Which of the following are recognized as treatment options?

A. Testosterone injections B. Couples therapy C. Cognitive therapy D. All of the above.

ANS: D

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Hypoactive sexual desire disorder has been treated in men and women with testosterone. Cognitive behavioral therapies and relationship therapies have been identified as most beneficial when combined together. Couples therapy has been identified as a beneficial focus when partner incompatibility with regard to sexual desire is identified as an issue.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. A psychiatric nursing instructor is teaching about the psychological effects of the diagnosis of a sexually transmitted disease (STD). Which student statement indicates that further instruction is needed?

A. STDs carry strong connotations of illicit sex and considerable social stigma.

B. STDs can cause insanity.

C. The diagnosis of HIV can generate hopelessness and helplessness.

D. Antibiotics administered in the early stages can cure all STDs. ANS: D The instructor should identify the need for further instruction if a student states that antibiotics can cure all STDs. STDs refer to infections that are contracted primarily through sexual activities or intimate contact. An example of an incurable STD is HIV. STDs are at epidemic levels in the United States.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity 11. A client reports, during his visit to the mental health clinic, that he is distressed by repetitive sexual fantasies that involve humiliating his sexual partner. This would most appropriately be assessed as what type of disorder?

A. Paraphilic disorder B. Obsessive-compulsive disorder C. Erectile disorder D. Hypoactive sexual desire disorder ANS: A Paraphilic disorders include repetitive or preferred sexual fantasies or behaviors that involve nonhuman objects, suffering or humiliation to oneself or ones partner, or nonconsenting persons. Diagnostic criteria include a duration of symptoms for at least 6 months and clinically significant distress caused by the symptoms.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. A nurse is counseling a client diagnosed with gender dysphoria. Which characteristic would differentiate this disorder from transvestic disorder?

A. Clients diagnosed with transvestic disorder are dissatisfied with their gender, whereas clients diagnosed with gender dysphoria are not.

B. Clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not.

C. Clients diagnosed with gender dysphoria never engage in cross-dressing, whereas clients diagnosed with transvestic disorder do.

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D. Clients diagnosed with transvestic disorder never engage in cross-dressing, whereas clients diagnosed with gender dysphoria do.

ANS: B The nurse should identify that clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not. Both clients diagnosed with gender dysphoria and transvestic disorder may participate in cross-dressing.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 13. Which of the following characteristics should a nurse identify as normal in the development of human sexuality for an 11-year-old child? Select all that apply.

A. The child experiments with masturbation.

B. The child may experience homosexual play.

C. The child shows little interest in the opposite sex.

D. The child shows little concern about physical attractiveness.

E. The child is unlikely to want to undress in front of others.

ANS: A, B, E The nurse should identify that experimenting with masturbation and homosexual play and not wanting to undress in front of others are characteristics that are normal in the development of human sexuality in an 11year-old child. Interest in the opposite sex usually increases during this age, and children often become selfconscious about their bodies.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. A nursing instructor is teaching about the various categories of paraphilic disorders. Which of the following categories are correctly matched with expected behaviors? Select all that apply.

A. Exhibitionistic disorder: Mary models lingerie for a company that specializes in home parties.

B. Voyeuristic disorder: John is arrested for peering in a neighbors bathroom window.

C. Frotteuristic disorder: Peter enjoys subway rush-hour female contact that results in arousal.

D. Pedophilic disorder: George can experience an orgasm by holding and feeling shoes.

E. Fetishistic disorder: Henry masturbates into his wifes silk panties.

ANS: B, C, E Categories of paraphilia include voyeurism (observing unsuspecting people who are naked, dressing, or engaged in sexual activity), frotteurism (touching or rubbing against a nonconsenting person), fetishism (using nonliving objects in sexual ways), and pedophilia (recurrent sexual urges involving sexual activity with a prepubescent child). Exhibitionism is a paraphilia but involves the urge to show ones genitals to unsuspecting strangers.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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Chapter 31. Eating Disorders Multiple Choice 1. A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice?

A. This therapy will increase the clients motivation to gain weight.

B. This therapy will reward the client for perfectionist achievements.

C. This therapy will provide the client with control over behavioral choices.

D. This therapy will protect the client from parental overindulgence.

ANS: C The nurse should identify that behavior modification therapy will be used because it provides the client with control over behavioral choices. Clients diagnosed with anorexia nervosa are often allowed to contract privileges based on weight gain. The client maintains control over eating and exercise.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a clients home environment should a nurse associate with the development of this disorder?

A. The home environment maintains loose personal boundaries.

B. The home environment places an overemphasis on food.

C. The home environment is overprotective and demands perfection.

D. The home environment condones corporal punishment.

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be an influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. A clients altered body image is evidenced by claims of feeling fat, even though the client is emaciated.

Which is the appropriate outcome criterion for this clients problem?

A. The client will consume adequate calories to sustain normal weight.

B. The client will cease strenuous exercise programs.

C. The client will perceive an ideal body weight and shape as normal.

D. The client will not express a preoccupation with food.

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self on the basis of self-attributes instead of appearance

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and to realize that perfection is unrealistic.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 4. A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding?

A. The emesis produced during purging is acidic and corrodes the tooth enamel.

B. Purging causes the depletion of dietary calcium.

C. Food is rapidly ingested without proper mastication.

D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 5. Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders?

A. These programs help clients correct distorted body image.

B. These programs address underlying client anger.

C. These programs help clients manage uncontrollable behaviors.

D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because the programs allow clients to maintain control. Issues of control are central to the etiology of these disorders.

Behavior modification techniques aid in restoring healthy body weight.

KEY: Cognitive Level: Application | Integrated Processes: Planning | Client Need: Psychosocial Integrity 6. A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition.

Anorexia nervosa is diagnosed. Which client statement best reflects a theory about the underlying etiology of this disorder?

A. I was just trying to be like everyone else.

B. All the skaters on the team are following an approved 1,200-calorie diet.

C. When I lose skating competitions, I also lose my appetite.

D. I am angry at my mother. I can get her approval only when I win competitions.

ANS: D This client statement reflects a possible underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family members development of anorexia nervosa.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 7. The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply?

A. Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions.

B. Family intervention and support are important in your childs recovery.

C. Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support.

D. Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed.

ANS: B The nurse should educate the family on the importance of family dynamics, involvement, and support in the treatment of anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder or impede the progress of recovery.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?

A. The client gains 2 pounds in 1 week.

B. The client focuses conversations on nutritious food.

C. The client demonstrates healthy coping mechanisms that decrease anxiety.

D. The client verbalizes an understanding of the etiology of the disorder.

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication?

A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Lorcaserin (Belviq) D. Pemoline (Cylert) ANS: C Lorcaserin was approved by the FDA in 2012. It suppresses the appetite by altering various 5-HT2C serotonin receptors. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred?

A. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.

B. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.

C. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not.

D. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

ANS: A The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food, followed by purging.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity 11. A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100-mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense?

A. 25 mL B. 20 mL C. 15 mL D. 10 mL ANS: C Twenty mg of Prozac multiplied by three results in the calculated 60-mg daily dose ordered by the physician.

Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time?

A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity ANS: B

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Based on Maslows hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 13. A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client?

A. The client will use stress-reducing techniques to avoid purging.

B. The client will discuss chaos in personal life and be able to verbalize a link to purging.

C. The client will gain 2 pounds prior to the next weekly appointment.

D. The client will remain free of signs and symptoms of malnutrition and dehydration.

ANS: C The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, and measurable and also include a time frame.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity 14. When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this clients symptoms?

A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis ANS: C Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this clients fainting to the loss of alkaline stool due to laxative abuse, which would lead to a relative metabolic acidotic condition.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 15. A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients?

A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat ANS: C

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The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 16. A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention?

A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan ANS: B By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight.

Which subjective client response would the nurse assess to support this medical diagnosis?

A. I do not use any laxatives or diuretics to lose weight.

B. I am losing lots of hair. Its coming out in handfuls.

C. I know that I am thin, but I refuse to be fat!

D. I dont know why people are worried. I need to lose this weight.

ANS: D When the client states, I dont know why people are worried. I need to lose this weight, the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis?

A. The client will identify two alternative methods of dealing with isolation by day 3.

B. The client will appropriately express angry feelings about lack of control by week 2.

C. The client will verbalize two positive self attributes by day 3.

D. The client will list five ways that the body reacts to bingeing and purging.

ANS: A

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The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 19. A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time?

A. To shift the clients focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation ANS: C When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 20. Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa?

A. Provide privacy during meals.

B. Remain with the client for at least 1 hour after the meal.

C. Encourage the client to keep a journal to document types of food consumed.

D. Restrict client privileges when provided food is not completely consumed.

ANS: B A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity Multiple Response 21. A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions?

Select all that apply.

A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa ANS: A, B

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The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and treating bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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Chapter 32. Personality Disorders Multiple Choice 1. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior?

A. You are very disrespectful. You need to learn to control yourself.

B. I understand that you are angry, but this behavior will not be tolerated.

C. What behaviors could you modify to improve this situation?

D. What anti-personality-disorder medications have helped you in the past?

ANS: B The appropriate nursing statement is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the treatment of a personality disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. A client diagnosed with antisocial personality disorder comes to a nurses station at 11:00 p.m., requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate?

A. Go ahead and use the phone. I know this pending divorce is stressful.

B. You know better than to break the rules. Im surprised at you.

C. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow.

D. The decision to divorce should not be considered until you have had a good nights sleep.

ANS: C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

A. Provide objective evidence that violence is unwarranted.

B. Initially restrain the client to maintain safety.

C. Use clear, calm statements and a confident physical stance.

D. Empathize with the clients paranoid perceptions.

ANS: C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of

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safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 4. A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data?

A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder ANS: C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?

A. Allow the clients to apply the democratic process when developing unit rules.

B. Maintain consistency of care by open communication to avoid staff manipulation.

C. Allow the client spokesperson to verbalize concerns during a unit staff meeting.

D. Maintain unit order by the application of autocratic leadership.

ANS: B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?

A. Being firm, consistent, and empathetic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to societal norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains ANS: A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with

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borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder?

A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security ANS: C A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of suffering in silence. Which underlying cause of this clients personality disorder should a nurse recognize?

A. Nurturance was provided from many sources, and independent behaviors were encouraged.

B. Nurturance was provided exclusively from one source, and independent behaviors were discouraged.

C. Nurturance was provided exclusively from one source, and independent behaviors were encouraged.

D. Nurturance was provided from many sources, and independent behaviors were discouraged.

ANS: B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply?

A. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone.

B. Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, whereas clients diagnosed with avoidant personality disorder do not.

C. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant.

D. Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, whereas

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clients diagnosed with avoidant personality disorder remain based in reality.

ANS: A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection, which leads to social isolation.

Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered?

A. I really dont have a problem. My family is inflexible, and every relative is out to get me.

B. I am so excited about working with you. Have you noticed my new nail polish, Ruby Red Roses?

C. I spend all my time tending my bees. I know a whole lot of information about bees.

D. I am getting a message from the beyond that we have been involved with each other in a previous life.

ANS: D The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred?

A. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling.

B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs.

C. They tend to develop few relationships because they are strongly independent but generally maintain deep affection.

D. They pay particular attention to details, which can frustrate the development of relationships.

ANS: B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 12. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder?

A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness

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C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others ANS: D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 13. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit?

A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body ANS: B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder?

A. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay.

B. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you dont stay with me.

C. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please dont go! I cant sleep without you being here.

D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me.

ANS: D The clients statement I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

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A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others ANS: A The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 16. Using a behavioral approach, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder?

A. Seclude the client when inappropriate behaviors are exhibited.

B. Contract with the client to reinforce positive behaviors with unit privileges.

C. Teach the purpose of antianxiety medications to improve medication compliance.

D. Encourage the client to journal feelings to improve awareness of abandonment issues.

ANS: B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder?

A. You really dont have to go by that schedule. Id just stay home sick.

B. There has got to be a hidden agenda behind this schedule change.

C. Who do you think you are? I expect to interact with the same nurse every Saturday.

D. You cant make these kinds of changes! Isnt there a rule that governs this decision?

ANS: D The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity.

Individuals diagnosed with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. Looking at a slightly bleeding paper cut, the client screams, Somebody help me, quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of which personality disorder?

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A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder ANS: C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over-gregarious, and seductive.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 19. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder?

A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment ANS: C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Psychosocial Integrity 20. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder?

A. The client experiences unwanted, intrusive, and persistent thoughts.

B. The client experiences unwanted, repetitive behavior patterns.

C. The client experiences inflexibility and lack of spontaneity when dealing with others.

D. The client experiences obsessive thoughts that are externally imposed.

ANS: C The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious and formal and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 21. Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors?

A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder

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C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder ANS: B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment: Management of Care 22. When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome?

A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites ANS: C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 23. The nurse plans to confront a client about secondary gains related to extreme dependency on her spouse.

Which nursing statement would be most appropriate?

A. Do you believe dependency issues have been a lifelong concern for you?

B. Have you noticed any anxiety during times when your husband makes decisions?

C. What do you know about individuals who depend on others for direction?

D. How have the specifics of your relationship with your spouse benefited you?

ANS: D When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that they might not otherwise receive.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 24. The nurse should recognize which factors that distinguish personality disorders from psychosis?

A. Functioning is more limited in personality disorders than in psychosis.

B. Major disturbances of thought are absent in personality disorders.

C. Personality disordered clients require hospitalization more frequently.

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D. Personality disorders do not affect family relationships as much as psychosis.

ANS: B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 25. Which client statement would demonstrate a common characteristic of Cluster B personality disorder?

A. I wish someone would make that decision for me.

B. I built this building by using materials from outer space.

C. Im afraid to go to group because it is crowded with people.

D. I didnt have the money for the ring, so I just took it.

ANS: D Antisocial personality disorder is included in the Cluster B personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes?

A. Provide external limits on client behavior.

B. Foster discussions of rationales for behavioral change.

C. Implement interventions consistently by only one staff member.

D. Encourage the client to involve self in care.

ANS: A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 27. Which characteristics should a nurse recognize as being exhibited by individuals diagnosed with any personality disorder?

A. These clients accept and are comfortable with their altered behaviors.

B. These clients understand that their altered behaviors result from anxiety.

C. These clients seek treatment to avoid interpersonal discomfort.

D. These clients avoid relationships due to past negative experiences.

ANS: A Clients who are diagnosed with personality disorders accept and are comfortable with their altered behaviors.

Personalities that develop in a disordered pattern remain somewhat unstable and unpredictable throughout the

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lifetime.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 28. A nurse would expect a client diagnosed with schizotypal personality disorder to exhibit which characteristic?

A. The client has many friends and associates but prefers to interact in small groups.

B. The client has many brief but intense relationships.

C. The client experiences incorrect interpretations of external events.

D. The client exhibits lack of tender feelings toward others.

ANS: C Clients who are diagnosed with schizotypal personality disorder experience odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms. This results in incorrect interpretations of external events.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 29. While improving, a client demands to have a phone installed in the intensive care unit (ICU) room. When a nurse states, This is not allowed; it is a unit rule, the client angrily demands to see the doctor. Which approach should the nurse use in this situation?

A. Provide an explanation for the necessity of the unit rule.

B. Assist the client to discuss anger and frustrations.

C. Call the physician and relay the request.

D. Arrange for a phone to be installed in the clients unit room.

ANS: B Clients who demand special privileges may be diagnosed with narcissistic personality disorder. The best approach in this situation is for the nurse to identify the function that anger, frustration, and rage serve for the client. The verbalization of feelings may help the client to gain insight into his or her behavior.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 30. Which nursing statement reflects a common characteristic of a client diagnosed with paranoid personality disorder?

A. This client consistently criticizes care and has difficulty getting along with others.

B. This client is shy and fades into the background.

C. This client expects special treatment, and setting limits will be necessary.

D. This client is expressive during group and is very pleased with self.

ANS: A A client diagnosed with paranoid personality disorder has a pervasive distrust and suspiciousness of others.

Anticipating humiliation and betrayal, the paranoid individual characteristically learns to attack first.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 31. A client exhibits dependency on staff and peers and expresses fear of abandonment. Using Mahlers theory of object relations, which should the nurse expect to note in this clients childhood?

A. Lack of fulfillment of basic needs by parental figures B. Absence of the clients maternal figure during symbiosis C. Difficulty establishing trust with the maternal figure D. Inconsistency by the maternal figure during individuation ANS: D During phase 3 (5 to 36 months) of Margaret Mahlers individuation theory, there should be a strengthening of the ego and an acceptance of self with independent ego boundaries. Inconsistency by the maternal figure during individuation may in later years result in feelings of helplessness when the client is alone because of exaggerated fears of being unable to care for self.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 32. A client diagnosed with Cluster C traits sits alone and ignores others attempts to converse. When ask to join a group the client states, No, thanks. In this situation, which should the nurse assign as an initial nursing diagnosis?

A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues ANS: B Clients diagnosed with Cluster C traits are described as anxious and fearful. The DSM-5 divides Cluster C personality disorders into three categories: avoidant, dependent, and obsessive-compulsive. Anxiety and fear contribute to social isolation.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity Multiple Response 33. Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder?

Select all that apply.

A. The client will relate one empathetic statement toward another client in group, by day 2.

B. The client will identify one personal limitation by day 1.

C. The client will acknowledge one strength that another client possesses by day 2.

D. The client will list four personal strengths by day 3.

E. The client will list two lifetime achievements by discharge.

ANS: A, B, C

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The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. An exaggerated sense of self-worth, a lack of empathy, and exploitation of others are characteristics of narcissistic personality disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 34. A nurse is caring for a group of clients within the DSM-5 Cluster B category of personality disorders.

Which factors should the nurse consider when planning client care? Select all that apply.

A. These clients have personality traits that are deeply ingrained and difficult to modify.

B. These clients need medications to treat the underlying physiological pathology.

C. These clients use manipulation, making the implementation of treatment problematic.

D. These clients have poor impulse control that hinders compliance with a plan of care.

E. These clients commonly have secondary diagnoses of substance abuse and depression.

ANS: A, C, D, E The nurse should consider that individuals diagnosed with cluster Btype personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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Chapter 33. Children and Adolescents Multiple Choice 1. Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual disability?

A. The client can perform some self-care activities independently.

B. The client has advanced speech development.

C. Other than possible coordination problems, the clients psychomotor skills are not affected.

D. The client communicates wants and needs by acting out behaviors.

ANS: D The nurse should identify that a client diagnosed with severe intellectual disability may communicate wants and needs by acting out behaviors. Severe intellectual disability indicates an IQ between 20 and 34. Individuals diagnosed with severe intellectual disability require complete supervision and have minimal verbal skills and poor psychomotor development.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 2. Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate intellectual disability?

A. Meeting all of the clients self-care needs to avoid injury B. Providing simple directions and praising clients independent self-care efforts C. Avoiding interference with the clients self-care efforts in order to promote autonomy D. Encouraging family to meet the clients self-care needs to promote bonding ANS: B Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate intellectual disability. Individuals with moderate intellectual disability can perform some activities independently and may be capable of academic skill to a second-grade level.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 3. A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, Im such a terrible mother. What did I do to cause this? Which nursing reply is most appropriate?

A. Researchers really dont know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored.

B. Poor parenting doesnt cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control.

C. Research has shown that the mother appears to play a greater role in the development of this disorder than the father.

D. Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?

ANS: B

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The most appropriate reply by the nurse is to explain to the parent that autism spectrum disorder is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism spectrum disorder occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 4. In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome?

A. The client will communicate all needs verbally by discharge.

B. The client will participate with peers in a team sport by day 4.

C. The client will establish trust with at least one caregiver by day 5.

D. The client will perform most self-care tasks independently.

ANS: C The most realistic client outcome for a child diagnosed with autism spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact.

This outcome relates to the nursing diagnosis impaired social interaction.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 5. After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss?

A. The pharmacological action of Ritalin causes a decrease in appetite.

B. Hyperactivity seen in ADHD causes increased caloric expenditure.

C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased.

D. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: A The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss.

Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 6. An adolescent client who was diagnosed with conduct disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. How should the nurse apply knowledge of conduct disorder to this clients situation?

A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood.

B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood.

C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely.

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D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: A The nurse should apply knowledge of conduct disorder to determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 7. Which finding would be most likely in a child diagnosed with separation anxiety disorder?

A. The child has a history of antisocial behaviors.

B. The childs mother is diagnosed with an anxiety disorder.

C. The child previously had an extroverted temperament.

D. The childs mother and father have an inconsistent parenting style.

ANS: B The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child diagnosed with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A child has been recently diagnosed with mild intellectual disability (ID). What information about this diagnosis should the nurse include when teaching the childs mother?

A. Children with mild ID need constant supervision.

B. Children with mild ID develop academic skills up to a sixth-grade level.

C. Children with mild ID appear different from their peers.

D. Children with mild ID have significant sensory-motor impairment.

ANS: B The nurse should inform the childs mother that children with mild ID develop academic skills up to a sixthgrade level. Individuals with mild ID are capable of independent living, capable of developing social skills, and have normal psychomotor skills.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 9. A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual disability (ID). Which student statement indicates that further instruction is needed?

A. These clients can work in a sheltered workshop setting.

B. These clients can perform some personal care activities.

C. These clients may have difficulties relating to peers.

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D. These clients can successfully complete elementary school.

ANS: D The nursing student needs further instruction about moderate mental retardation because individuals diagnosed with moderate ID are capable of academic skill up to only a second-grade level. Moderate ID reflects an IQ range of 35 to 49.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 10. Which nursing intervention should be prioritized when caring for a child diagnosed with intellectual disability?

A. Encourage the parents to always prioritize the needs of the child.

B. Modify the childs environment to promote independence and encourage impulse control.

C. Delay extensive diagnostic studies until the child is developmentally mature.

D. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

ANS: B The nurse should prioritize modifying the childs environment to promote independence and encourage impulse control. This intervention is related to the nursing diagnosis self-care deficit. Positive reinforcement can serve to increase self-esteem and encourage repetition of behaviors.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 11. A preschool child is admitted to a psychiatric unit with a diagnosis of autism spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this clients plan of care?

A. Encourage and reward peer contact.

B. Provide consistent caregivers.

C. Provide a variety of safe daily activities.

D. Maintain close physical contact throughout the day.

ANS: B The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autism spectrum disorder. Children diagnosed with autism spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate?

A. Place client in restraints until the aggression subsides.

B. Sedate the client with neuroleptic medications.

C. Hold clients head steady and apply a helmet.

D. Distract the client with a variety of games and puzzles.

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ANS: C The most appropriate intervention for head banging is to hold the clients head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the clients head from injury.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 13. When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourettes disorder?

A. Antipsychotic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor medications ANS: A The nurse should recognize that antipsychotic medications are effective in the treatment of Tourettes disorder.

These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Risperidone (Risperdal) has been shown to reduce symptoms by 21% to 61%.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 14. Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders?

A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life ANS: B The nurse should reinforce positive actions to encourage repetition of desired behaviors when caring for children diagnosed with a disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 15. A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity.

Which outcome would best address this clients diagnosis?

A. The client will name own body parts as separate from others by day 5.

B. The client will establish a means of communicating personal needs by discharge.

C. The client will initiate social interactions with caregivers by day 4.

D. The client will not harm self or others by discharge.

ANS: A

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An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 16. A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this childs behavior. Which student response indicates an appropriate evaluation of the situation?

A. This childs behavior must be evaluated according to developmental norms.

B. This child has symptoms of attention deficit hyperactivity disorder.

C. This child has symptoms of the early stages of autistic disorder.

D. This childs behavior indicates possible symptoms of oppositional defiant disorder.

ANS: A The students evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 17. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of intellectual disability?

A. Risk for injury R/T self-mutilation B. Altered social interaction R/T nonadherence to social convention C. Altered verbal communication R/T delusional thinking D. Social isolation R/T severely decreased gross motor skills ANS: B The appropriate nursing diagnosis associated with this degree of intellectual disability is altered social interaction R/T nonadherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual disability and may also experience some limitations in speech communications.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 18. A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents?

A. If one dose of Ritalin is missed, double the next dose.

B. Administer Ritalin to the child after breakfast.

C. Administer Ritalin to the child just prior to bedtime.

D. A side effect of Ritalin is decreased ability to learn.

ANS: B

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The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 19. Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder?

A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection.

B. Convey unconditional acceptance and positive regard.

C. Recognize escalating aggressive behaviors and intervene before violence occurs.

D. Provide immediate positive feedback for appropriate behaviors.

ANS: C The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behaviors and to intervene before violence occurs. This intervention serves to keep the client and others safe. This is the priority nursing concern.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 20. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her childs attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mothers concern?

A. The physician will probably switch from Ritalin to a central nervous system stimulant.

B. The physician may prescribe an antihistamine with the Ritalin to improve effectiveness.

C. Your child has probably developed a tolerance to Ritalin and may need a higher dosage.

D. Your child has developed sensitivity to Ritalin and may be exhibiting an allergy.

ANS: C The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate (Ritalin) is a central nervous system stimulant in which tolerance can develop rapidly. Physical and psychological dependence can also occur.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first?

A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu C. A client diagnosed with conduct disorder who is demanding special attention from staff D. A client diagnosed with attention deficit disorder who has a history of self-mutilation ANS: B A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 22. A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works?

A. Ritalins sedation side effect assists children by decreasing their energy level.

B. How Ritalin works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD. C. Ritalin helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapse.

D. Ritalin decreases hyperactivity by increasing serotonin levels.

ANS: B It is unknown how Ritalin works, but even though it is a stimulant, it does decrease hyperactivity in individuals diagnosed with ADHD. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 23. An 8-year-old client diagnosed with attention deficit-hyperactivity disorder (ADHD) was admitted 5 days ago for management of temper tantrums. What would be a priority nursing intervention during the termination phase of the nurseclient relationship?

A. Set a contract with the client to limit acting-out behaviors while hospitalized.

B. Teach the importance of taking fluoxetine (Prozac) consistently, even when feeling better.

C. Discuss behaviors that are and are not acceptable on the unit.

D. Ask the client to demonstrate learned coping skills without direction from the nurse.

ANS: D The priority nursing intervention during the termination phase of the nurseclient relationship should include encouraging the client to demonstrate the coping skills learning during the working phase of the nurseclient relationship.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 24. A child diagnosed with attention deficit-hyperactivity disorder (ADHD) is having difficulty completing homework assignments. What information should the nurse include when teaching the parents about task performance improvement?

A. The parents should isolate the child when completing homework to improve focus.

B. The parents should withhold privileges if homework is not completed within a 2-hour period.

C. The parents should divide the homework task into smaller steps and provide an activity break.

D. The parents should administer an extra dose of methylphenidate (Ritalin) prior to homework.

ANS: C By dividing the homework task into smaller steps, the child can remain more focused within a limited about of time. Physical activity can release pent-up energy that would distract from task completion.

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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 25. A nursing instructor is teaching about pharmacological treatments for attention deficit-hyperactivity disorder (ADHD). Which information about atomoxetine (Strattera) should be included in the lesson plan?

A. Strattera, unlike methylphenidate (Ritalin), is a central nervous system depressant.

B. When taking Strattera, a client should eliminate all red food coloring from the diet.

C. Strattera will be a life-long intervention for clients diagnosed with this disorder.

D. Strattera, unlike methylphenidate (Ritalin), is a selective norepinephrine reuptake inhibitor.

ANS: D Strattera is a selective norepinephrine reuptake inhibitor. Ritalin is classified as a stimulant. The exact mechanism by which these drugs produce a therapeutic effect in ADHD is unknown.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Multiple Response 26. Which of the following risk factors noted during a family history assessment should a nurse associate with the potential development of intellectual disability? Select all that apply.

A. A family history of Tay-Sachs disease B. Childhood meningococcal infection C. Deprivation of nurturance and social contact D. History of maternal multiple motor and verbal tics E. A diagnosis of maternal major depressive disorder ANS: A, B, C The nurse should associate a family history of Tay-Sachs disease, childhood meningococcal infections, and deprivation of nurturance and social contact as risk factors that would predispose a child to intellectual disability. Major predisposing factors of intellectual disability include: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, environmental influences, and other mental disorders.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 27. Which of the following interventions should a nurse anticipate implementing when planning care for children diagnosed with attention deficit-hyperactivity disorder (ADHD)? Select all that apply.

A. Behavior modification B. Antianxiety medications C. Competitive group sports D. Group therapy E. Family therapy

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ANS: A, D, E The nurse should anticipate that behavior modification, group therapy, and family therapy may be implemented in the management of ADHD in children. These interventions are often used in conjunction with psychopharmacology to reduce impulsive and hyperactive behaviors and to increase attention span.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 28. The nurse should recognize which of the following findings contribute to a clients development of attention deficit-hyperactivity disorder (ADHD)? Select all that apply.

A. The clients father was a smoker.

B. The client was born 7 weeks premature.

C. The client is lactose intolerant.

D. The client has a sibling diagnosed with ADHD. E. The client has been diagnosed with dyslexia.

ANS: B, D The nurse should identify that premature birth and having a sibling diagnosed with ADHD would predispose a client to the development of ADHD. Research indicates evidence of genetic influences in the etiology of ADHD. Studies also indicate that environmental influences such as lead exposure and diet can be linked with the development of ADHD. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Physiological Integrity

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Chapter 34. The Aging Individual Multiple Choice 1. A client has recently been placed in a long-term-care facility because of marked confusion and inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the clients self-esteem?

A. Leave the client alone in the bathroom to test ability to perform self-care.

B. Assign a variety of caregivers to increase potential for socialization.

C. Allow client to choose between two different outfits when dressing for the day.

D. Modify the daily schedule often to maintain variety and decrease boredom.

ANS: C The most appropriate nursing intervention to maintain this clients self-esteem is to allow the client to choose between two different outfits when dressing for the day. The nurse should also provide appropriate supervision to keep the client safe, maintain consistency of caregivers, and maintain a structured daily routine to minimize confusion.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. A son who recently brought his extremely confused parent to a nursing home for admission reports feelings of guilt. Which is the appropriate nursing reply?

A. People often have mixed emotions about decisions like this. Support groups are held here on Mondays for children of residents in similar situations.

B. You did what you had to do. I wouldnt feel guilty if I were you.

C. Support groups are available to low-income families.

D. Your parent is doing just fine. Well take very good care of him.

ANS: A The most appropriate reply by the nurse is to normalize the sons feelings and provide a resource to help the son deal with feelings of guilt by giving information about an available support group.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A family asks why their father is attending activity groups at the long-term care facility. The son states, My father worked hard all of his life. He just needs some rest at this point. Which is the appropriate nursing reply?

A. Im glad we discussed this. Well excuse him from the activity groups.

B. The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation.

C. The groups are optional. Only clients at high functioning levels would benefit.

D. If your father doesnt go to these activity groups, he will be at high risk for developing dementia.

ANS: B The most appropriate nursing reply is to educate the family on the purpose of activity groups, which is to provide social interaction, sensory stimulation, and reality orientation. Groups can also serve to increase self-

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esteem and reduce depression.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 4. A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred?

A. Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives.

B. Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution.

C. Reminiscence therapy is a social group where members chat about past events and future plans.

D. Reminiscence therapy encourages members to share positive memories of significant life transitions.

ANS: B Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution. Stimulation of life memories serves to help older clients work through their losses and maintain self-esteem. Reminiscence therapy can take place in one-on-one or group settings.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 5. A couple resides in a long-term care facility. The husband is admitted to the psychiatric unit after physically abusing his wife. He states, My wife is having an affair with a young man, and I want it investigated. Which is the appropriate nursing reply?

A. Your wife is not having an affair. What makes you think that?

B. Why do you think that your wife is having an affair?

C. Your wife has told us that these thoughts have no basis in fact.

D. I understand that you are upset. Lets talk about it.

ANS: D The most appropriate reply by the nurse is to empathize with the client regarding his emotional response and to encourage the client to talk about the situation. The nurse should remain nonjudgmental and help maintain orientation and aid in memory and recognition.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. Which psychiatric disorder would a nurse expect to see diagnosed in a clients later life?

A. Schizophrenia B. Major depressive disorder C. Phobic disorder D. Dependent personality disorder ANS: B Major depressive disorder is most likely to be identified later in life. Depression among older adults can be

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increased by physical illness, functional disability, cognitive impairment, and loss of a spouse.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 7. An elderly client who lives with a caregiver is admitted to an emergency department for a fractured arm.

The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect?

A. Inability for the client to meet self-care needs B. Alzheimers dementia C. Abuse, neglect, or both D. Caregiver role strain ANS: C The nurse should expect that this client is a victim of elder abuse, neglect, or both. Indicators of elder physical abuse include bruises, fractures, burns, and other physical injuries. Neglect may be manifested as hunger, poor hygiene, unattended physical problems, and/or abandonment.

KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Safe and Effective Care Environment 8. An elderly, emaciated client is brought to an emergency department by the clients caregiver. The client has bruises and abrasions on shoulders and back in multiple stages of healing. When directly asked about these symptoms, which type of client response should a nurse anticipate?

A. The client will honestly reveal the nature of the injuries.

B. The client may deny or minimize the injuries.

C. The client may have forgotten what caused the injuries.

D. The client will ask to be placed in a nursing home.

ANS: B The nurse should anticipate that the client might deny or minimize the injuries. The older client may be unwilling to disclose information because of fear of retaliation, embarrassment about the existence of abuse in the family, protectiveness toward a family member, or unwillingness to bring about legal action.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. A client diagnosed with neurocognitive disorder due to Alzheimers disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication?

A. Discourage attempts at verbal communication because of increased client frustration.

B. Increase the volume of the nurses communication responses.

C. Verbalize the nurses perception of the implied communication.

D. Encourage the client to communicate by writing.

ANS: C The most appropriate nursing intervention is to verbalize the nurses perception of the implied communication.

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The nurse should also keep explanations simple, use face-to-face interaction, and speak slowly without shouting.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. An elderly client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen?

A. Altered cortical and intellectual functioning B. Altered respiratory and gastrointestinal functioning C. Altered liver and kidney functioning D. Altered endocrine and immune system functioning ANS: C The nurse should question the use of an antidepressant medication in a client with altered liver and kidney function. Antidepressant medication should be administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity. Because of these changes, medications can reach high levels despite moderate oral dosage.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 11. An elderly client has met the criteria for a diagnosis of major depressive disorder. The client does not respond to antidepressant medications. Which treatment should a nurse anticipate that the physician would prescribe for this client?

A. Electroconvulsive therapy (ECT) B. Neuroleptic therapy C. An antiparkinsonian agent D. An anxiolytic agent ANS: A The nurse should anticipate that ECT will be ordered to treat this clients symptoms of depression. ECT remains one of the safest and most effective treatments for major depressive disorder in older adults. When a client does not respond to antidepressant medications or has been diagnosed with co-morbid disease processes that prohibit the use of antidepressant medications, ECT is considered the treatment of choice. The response to ECT may be slower in older clients, and the effects may be of limited duration.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 12. According to the U.S. Census Bureau criteria, how would a nurse classify a 70-year-old man?

A. This man would be classified as older.

B. This man would be classified as elderly.

C. This man would be classified as aged.

D. This man would be classified as very old.

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ANS: B The U.S. Census Bureau classifies a 70-year-old man as elderly. The U.S. Census Bureau has developed a system for classification of older Americans: older, 55 to 64; elderly, 65 to 74; aged, 75 to 84; very old, 85 years and older.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance 13. A nurse is conducting a class on fall prevention at a local senior center. In relationship to the slowed cognitive processing of advanced age, which teaching modification would be most appropriate for the nurse to implement?

A. Encouraging the clients to use hearing aids if needed B. Avoiding overarticulation C. Minimizing distractive stimuli D. Providing more time for client feedback ANS: D Because the elderly require more time to assimilate information, the nurse should modify teaching methods to allow more time for older adults to respond to and pose questions.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 14. A client diagnosed with glaucoma is being discharged to an assisted living facility. In what way should the discharge nurse modify teaching to most effectively present information to this client?

A. Repeat information at least four times.

B. Present discharge teaching to clients spouse.

C. Use a taped message that can be repeated as needed.

D. Reinforce critical content by providing large-print handouts.

ANS: D Providing large-print materials would address the clients visual alterations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

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Chapter 35. Survivors of Abuse or Neglect Multiple Choice 1. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the childs face and arms. What other symptom should indicate to the nurse that the child might have been physically abused?

A. The child shrinks at the approach of adults.

B. The child begs or steals food or money.

C. The child is frequently absent from school.

D. The child is delayed in physical and emotional development.

ANS: A The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns might be a victim of abuse. Whether or not the adult intended to harm the child, maltreatment should be considered.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 2. A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect?

A. The woman may be exhibiting a controlled response pattern.

B. The woman may have a history of childhood neglect.

C. The woman may be exhibiting codependent characteristics.

D. The woman might be a victim of incest.

ANS: D The nurse should suspect that this client might be a victim of incest. Women in abusive relationships often grew up in abusive homes.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence?

A. Power and control are central to the dynamic of domestic violence.

B. Poor communication and social isolation are central to the dynamic of domestic violence.

C. Erratic relationships and vulnerability are central to the dynamic of domestic violence.

D. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

ANS: A The nurse accurately states that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

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KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Psychosocial Integrity 4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate?

A. Discourage the client from discussing the event, as this may lead to further emotional trauma.

B. Remain nonjudgmental and actively listen to the clients description of the event.

C. Meet the clients self-care needs by assisting with showering and perineal care.

D. Provide cues, based on police information, to encourage further description of the event.

ANS: B The most appropriate nursing action is to remain nonjudgmental and actively listen to the clients description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. In the emergency department, a raped client appears calm and exhibits a blunt affect. The client answers a nurses questions in a monotone using single words. How should the nurse interpret this clients responses?

A. The client may be lying about the incident.

B. The client may be experiencing a silent rape reaction.

C. The client may be demonstrating a controlled response pattern.

D. The client may be having a compounded rape reaction.

ANS: C This client is most likely demonstrating a controlled response pattern. In a controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, Why doesnt she just leave him? Which is the nursing supervisors most appropriate reply?

A. These clients dont know life any other way, and change is not an option until they have improved insight.

B. These clients have limited skills and few vocational abilities to be able to make it on their own.

C. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation.

D. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.

ANS: D The nursing supervisor is accurate when stating that clients in severely abusive relationships are paralyzed into

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inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner for some of the following reasons: for the children, financial reasons, fear of retaliation, lack of a support network, religious reasons, and/or hopelessness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, The beatings have been getting worse, and Im afraid that next time he might kill me.

Which is the appropriate nursing reply?

A. Leopards dont change their spots, and neither will he.

B. There are things you can do to prevent him from losing control.

C. Lets talk about your options so that you dont have to go home.

D. Why dont we call the police so that they can confront your husband with his behavior?

ANS: C The most appropriate reply by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions independently without the nurse being the rescuer. Imposing judgments and giving advice is nontherapeutic.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner?

A. I know that it was not my fault.

B. My boyfriend has trouble controlling his sexual urges.

C. If I dont put myself in a dating situation, I wont be at risk.

D. Next time I will think twice about wearing a sexy dress.

ANS: A The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate selfworth.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. A nursing student asks an emergency department nurse, Why does a rapist use a weapon during the act of rape? Which nursing reply is most accurate?

A. A weapon is used to increase the victimizers security.

B. A weapon is used to inflict physical harm.

C. A weapon is used to terrorize and subdue the victim.

D. A weapon is used to mirror learned family behavior patterns.

ANS: C

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The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. When questioned about bruises, a woman states, It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it wont happen again. This client is in which phase of the cycle of battering?

A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase ANS: C The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse?

A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a safe house for battered women ANS: D The nurse should provide information about safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear for their lives.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 12. A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should a nurse recognize?

A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction ANS: C The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed

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response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 13. Which assessment data should a school nurse recognize as signs of physical neglect?

A. The child is often absent from school and seems apathetic and tired.

B. The child is very insecure and has poor self-esteem.

C. The child has multiple bruises on various body parts.

D. The child has sophisticated knowledge of sexual behaviors.

ANS: A The nurse should recognize that a child who is often absent from school and seems apathetic and tired might be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 14. An anorexic client states to a nurse, My father has recently moved back to town. Since that time the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated and lives alone. What should the nurse suspect?

A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood bulimia ANS: B The nurse should suspect that this client might have a history of childhood incest. Adult survivors of incest are at risk for developing posttraumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 15. When planning care for women in abusive relationships, which of the following information is important for the nurse to consider? Select all that apply.

A. It often takes several attempts before a woman leaves an abusive situation.

B. Substance abuse is a common factor in abusive relationships.

C. Until children reach school age, they are usually not affected by parental discord.

D. Women in abusive relationships usually feel isolated and unsupported.

E. Economic factors rarely play a role in the decision to stay in abusive relationships.

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ANS: A, B, D When planning care for women who have been victims of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported.

Children can be affected by domestic violence from infancy, and economic factors often play a role in the victims decision to stay.

KEY: Cognitive Level: Applications | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 16. Which of the following nursing diagnoses would be expected for an adult survivor of incest? Select all that apply.

A. Low self-esteem B. Powerlessness C. Disturbed personal identity D. Knowledge deficit E. Noncompliance ANS: A, B An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders. Disturbed personal identity refers to an inability to distinguish between self and nonself and is seen in disorders such as autistic disorders, borderline personality disorders, dissociative disorders, and gender identity disorders.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

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Chapter 36. Community Mental Health Nursing Multiple Choice 1. A nursing instructor is teaching students about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act?

A. Many perspective clients did not meet criteria for mental illness diagnostic-related groups.

B. Zoning laws discouraged the development of community mental health centers.

C. States could not match federal funds to establish community mental health centers.

D. There was not a sufficient employment pool to staff community mental health centers.

ANS: C A deterring factor to the proper implementation of the Community Mental Health Centers Act of 1963 was that states could not match federal funds to establish community mental health centers. This act called for the construction of comprehensive community mental health centers to offset the effects of deinstitutionalization caused by the closing of state mental health hospitals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 2. A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care?

A. Teaching an adolescent about pregnancy prevention B. Teaching an elderly client the reportable side effects of a newly prescribed neuroleptic medication C. Teaching a client with schizophrenia to cook meals, make a grocery list, and establish a budget D. Teaching a client about his or her new diagnosis of bipolar disorder ANS: C The nurse who teaches a client to cook meals, make a grocery list, and establish a budget is implementing care within the parameters of tertiary prevention. Tertiary prevention is services aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by promoting rehabilitation that is directed toward achievement of maximum functioning.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A nursing instructor is teaching about case management. What student statement indicates that learning has occurred?

A. Case management is a method used to achieve independent client care.

B. Case management provides coordination of services required to meet client needs.

C. Case management exists to facilitate client admission to needed inpatient services.

D. Case management is a method to facilitate physician reimbursement.

ANS: B The instructor evaluates that learning has occurred when a student defines case management as providing coordination of services required to meet client needs. Case management strives to organize client care so that

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specific outcomes are achieved within allotted time frames.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A client on the inpatient unit tells a student nurse, My life has no purpose. I cant think about living another day, but please dont tell anyone about the way I feel. I know you are obligated to protect my confidentiality.

Which is the most appropriate reply by the student nurse?

A. The treatment team is composed of many specialists who are working to improve your ability to function.

Sharing this information with the team is critical to your care.

B. Lets discuss steps that will resolve negative lifestyle choices that may increase your suicidal risk.

C. You seem to be preoccupied with self. You should concentrate on hope for the future.

D. This information is secure with me because of client confidentiality.

ANS: A The most appropriate response by the student nurse is to explain that sharing the information with the treatment team is critical to the clients care. The nurses priority is to ensure client safety and to inform others of the clients suicidal ideation.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 5. When intervening with a married couple experiencing relationship discord, which reflects a nursing intervention at the secondary level of prevention?

A. Assessing how the children are coping with the parents relationship issues B. Supplying the couple with guidelines related to marital seminar leadership C. Teaching the couple about various methods of birth control D. Counseling the couple in relation to open and honest communication skills ANS: D Counseling the couple in relation to open and honest communication skills is reflective of a nursing intervention at the secondary level of prevention. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. Providing nursing education on drug abuse to a high school class is an example of which level of preventive care?

A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Primary intervention ANS: A Providing nursing education on drug abuse to a high school class is an example of primary prevention. Primary

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prevention services are aimed at reducing the incidence of mental health disorders within the population.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance 7. A newly admitted homeless client diagnosed with schizophrenia states, I have been living in a cardboard box for 2 weeks. Why did the government let me down? Which is an appropriate nursing reply?

A. Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless.

B. Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia.

C. Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success.

D. Your discharge from the state hospital was based on presumed family support, and this was not forthcoming.

ANS: C The most accurate nursing reply is to explain to the client that the resources were not available for successful transitioning out of a state hospital to the community. There are several factors that are thought to contribute to homelessness among the mentally ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable health care, domestic violence, and addiction disorders.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A nursing instructor is teaching students about the differences between partial and inpatient hospitalization.

In what way does partial hospitalization differ from traditional inpatient hospitalization?

A. Partial hospitalization does not provide medication administration and monitoring.

B. Partial hospitalization does not use an interdisciplinary team.

C. Partial hospitalization does not offer a comprehensive treatment plan.

D. Partial hospitalization does not provide supervision 24 hours a day.

ANS: D The instructor should explain that partial hospitalization does not provide supervision 24 hours a day. Partial hospitalization programs generally offer a comprehensive treatment plan formulated by an interdisciplinary team. This has proved to be an effective method of preventing hospitalization.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 9. When a home health nurse administers an outpatients injection of haloperidol decanoate (Haldol decanoate), which level of care is the nurse providing?

A. Primary prevention level of care B. Secondary prevention level of care C. Tertiary prevention level of care D. Case management level of care

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ANS: C When administering this long-acting antipsychotic medication, the nurse is providing a tertiary prevention level of care. Tertiary prevention services are aimed at reducing the residual effects associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation directed toward achievement of maximum functioning.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. A client diagnosed with schizophrenia is hospitalized because of an exacerbation of psychosis related to antipsychotic medication nonadherence. Which level of care does the clients hospitalization reflect?

A. Primary prevention level of care B. Secondary prevention level of care C. Tertiary prevention level of care D. Case management level of care ANS: B The clients hospitalization reflects the secondary prevention level of care. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 11. When a nurse attempts to provide health-care services to the homeless, what should be a realistic concern?

A. Most individuals who are homeless reject help.

B. Most individuals who are homeless are suspicious of anyone who offers help.

C. Most individuals who are homeless are proud and will often refuse charity.

D. Most individuals who are homeless relocate frequently.

ANS: D A realistic concern in the provision of health-care services to the homeless is that individuals who are homeless relocate frequently. Frequent relocation confounds service delivery and interferes with providers efforts to ensure appropriate care.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 12. A homeless client comes to an emergency department reporting cough, night sweats, weight loss, and blood-tinged sputum. What disease that has recently become more prevalent among the homeless community should a nurse suspect?

A. Meningitis B. Tuberculosis C. Encephalopathy D. Mononucleosis

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ANS: B The nurse should suspect that the homeless client has contracted tuberculosis. Tuberculosis is a growing problem among homeless individuals because of being in crowded shelters, which are ideal conditions for the spread of respiratory tuberculosis. Alcoholism, drug addiction, HIV infection, and poor nutrition also contribute to the increase in cases of tuberculosis.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 13. A community health nurse is teaching a class to expectant parents. All participants lack infant care knowledge. A student nurse asks, If you had to assign a nursing diagnosis to this group, what would it be?

What is the best nursing reply?

A. I would assign the nursing diagnosis of cognitive deficit.

B. I would assign the nursing diagnosis of knowledge deficit.

C. I would assign the nursing diagnosis of altered family processes.

D. I would assign the nursing diagnosis of risk for caregiver role strain.

ANS: B Knowledge deficit is defined as the absence or deficiency of cognitive information related to a specific topic.

Cognitive deficit would indicate an alteration in the ability to process information, and this evidence is not provided in the question.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Health Promotion and Maintenance 14. A client diagnosed with schizophrenia was released from a state mental hospital after 20 years of institutionalization. A nurse should recognize which characteristic that is likely to be exhibited by this client?

A. The client is likely to be compliant with treatment because of institutional dependency.

B. The client is likely to find a variety of community support services to aid in the transition.

C. The client is likely to adjust to the community environment if given sufficient support.

D. The client is likely to be admitted at some time to an acute care unit for psychiatric treatment.

ANS: D Because of the chronic nature of this clients diagnosis and commonly occurring medication noncompliance, the nurse would expect recidivism during the course of the illness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 15. A 27-year-old client was diagnosed 5 years ago with schizophrenia. What course of treatment should the nurse expect to be implemented?

A. Eventual admission for long-term care in a psychiatric facility B. Community-based care with numerous brief hospitalizations C. Case management in the community with few relapses D. Occasional contact with outpatient counselors and psychiatrists

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ANS: B Community-based care is the standard of treatment that followed the deinstitutionalization movement.

Schizophrenia is a chronic disease that includes both exacerbations and remissions in the course of the illness, leading to numerous brief hospitalizations.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 16. Which intervention should the nurse consider as primary prevention for an individual who is on the verge of being homeless because of a job layoff?

A. Referral to primary care provider to improve general health status B. Encouraging client to recognize reasons for job layoff C. Job training to increase employment options D. Encouraging the use of prn medications to control symptoms ANS: C When the nurse implements primary prevention interventions, the nurse is providing services aimed at reducing the incidences of mental disorders within the population. In this situation, there is emphasis on providing education and support to unemployed or homeless individuals.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. Which nursing statement best describes the current nature of mental health care in the community?

A. All homeless people have a history of institutionalization and are frequently admitted to acute care settings.

B. In the United States, the rate of serious mental illness in the prison population is the same as the general population.

C. The deinstitutionalization movement in the United States was successful in transitioning clients into the community.

D. Today, the majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization.

ANS: D The majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization and reintroduction into the community. Crisis situations can occur because of treatment noncompliance and exacerbations of the chronic mental illness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity Multiple Response 18. Which of the following clients should a nurse recommend for a structured day program? Select all that apply.

A. An acutely suicidal teenager who has had three previous suicide attempts B. A chronically mentally ill woman who has a history of medication noncompliance C. An elderly individual with end-stage Alzheimers disease

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D. A depressed individual who is able to participate in a safety plan E. A client who is hearing voices that tell him or her to harm others ANS: B, D The nurse should recommend a structured day program for a chronically mental ill woman who has a history of medication noncompliance and for a depressed individual who is able to participate in a safety plan. Day programs (also called partial hospitalizations) are designed to prevent institutionalization or to ease the transition from inpatient hospitalization to community living.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment: Management of Care

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Chapter 37. The Bereaved Individual Multiple Choice 1. A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kbler-Rosss grief stage of anger?

A. The client registers for an iron-man marathon to be held in 9 months.

B. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him.

C. The client promises God to give up smoking if allowed to live long enough to witness a grandchilds birth.

D. The client gathers family in order to plan a funeral and make last wishes known.

ANS: B The nurse should assess that the client is in the anger stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kbler-Rosss grief process, in which the reality of the situation is realized and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. A nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, Im planning an elaborate wake and funeral. According to George Engel, what purpose would these rituals serve?

A. To delay the recovery process initiated by the loss of the clients spouse B. To facilitate the acceptance of the loss of the clients spouse C. To avoid dealing with grief associated with the loss of the clients spouse D. To eliminate emotional pain related to the loss of the clients spouse ANS: B The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the clients spouse. Resolution of the loss is the fourth stage in Engels grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how should a nurse expect the neighbors action to affect the womans grieving task completion?

A. This action may hamper the woman from accepting the reality of the loss.

B. This action would help the woman forget the sorrow and move on with life.

C. This action communicates full support from her neighbors.

D. This action would motivate the woman to look to the future and not the past.

ANS: A The nurse should anticipate that this action could hinder the woman from accepting the reality of the loss. The first task in Wordens grief process is to accept the reality of the loss. It is common for individuals to refuse to

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believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one so as not to have to face reality. The bereaved person is considered an active participant in the grief process and the above-mentioned behaviors are part of that process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client?

A. Denial of personal mortality B. Preoccupation with the loss C. Clinging behaviors and personal insecurity D. Acting-out behaviors, exhibited in aggression and defiance ANS: D The school nurse should anticipate that this teenager would exhibit aggression and acting-out behaviors.

Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to express sorrow by acting out rather than typical emotional expressions of the grieving process.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. What term should a nurse use when describing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior?

A. Falling out in the African American culture B. Body rocking in the Vietnamese American culture C. Conversion disorder in the Jewish American culture D. Spirit possession in the Native American culture ANS: A The nurse should use the term falling out to describe a sudden physical collapse and paralysis. This behavior is associated with the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding.

KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. Which grieving behaviors should a nurse anticipate when caring for a Southwest Navajo Indian client?

A. Celebrating the life of a deceased person with festivities and revelry B. Not expressing grief openly and reluctance to touch a dead body C. Holding a prayerful vigil for a week following the persons death D. Expressing grief openly and publicly and erecting an altar in the home to honor the dead ANS: B

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The nurse should identify that a Navajo client would not express grief openly and would be reluctant to touch a dead body. Navajo Indians do not bury the body of a deceased person for 4 days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 7. A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is needed?

A. In this culture, the color red is associated with death and is considered bad luck.

B. In this culture, there is an innate fear of death.

C. In this culture, emotions are not expressed openly.

D. In this culture, death and bereavement are centered on ancestor worship.

ANS: A The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck. Chinese Americans consider the color white as associated with death and both the colors black and white are considered bad luck. Red is the ultimate color of luck in this culture.

Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 8. The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurses assessment?

A. The clients spouse died 12 months ago.

B. The client still cries when recalling memories of the deceased.

C. The client reports feelings of worthlessness.

D. The client reports intermittent anxiety.

ANS: C Several authors identify loss of self-esteem as the differentiating factor between normal and maladaptive grieving. The length of time needed to grieve is variable, so it is difficult to establish a time frame as indicative of maladaptive grief.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process?

A. Stage I: Numbness or protest B. Stage II: Disequilibrium C. Stage III: Disorganization and despair D. Stage IV: Reorganization

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ANS: C The nurse should identify that this client is in the third stage of Bowlbys grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost individual may occur.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. Which is the most accurate description of the nursing diagnosis of spiritual distress?

A. The client reports no church affiliations.

B. The client struggles to identify meaning and purpose in life.

C. The client reports seeing the spirit of his deceased wife.

D. The client reports that meditation helps him feel connected spiritually.

ANS: B One common nursing diagnosis in relation to complicated grief (and some authors would argue that all grief is complicated) is the risk for spiritual distress, which addresses the persons sense of meaning, purpose, and outlook for the future.

KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity Multiple Response 11. A nurse is leading a bereavement group. Which of the following group members should the nurse identify as being at high risk for having difficulty grieving? Select all that apply.

A. A widower who has recently experienced the death of two good friends B. A man whose wife died suddenly after a cerebrovascular accident C. A widow who, after a year, allowed removal of life support from her terminally ill husband D. A woman who had a competitive relationship with her recently deceased brother E. A young couple whose child recently died of a genetic disorder ANS: A, B, D, E Several factors have been identified that may make the grief response more difficult: grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individuals physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. A widow who has experienced the process of loss for an extended period of time is more likely in the stage of acceptance and resolution of grief.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. An instructor is teaching nursing students about Wordens grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? Select all that apply.

A. Refusing to allow self to think painful thoughts

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B. Indulging in the pain of loss C. Using alcohol and drugs D. Idealizing the object of loss E. Recognizing that time will heal ANS: A, C, D The nurse should identify that refusing to allow self to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Wordens grief process is working through the pain or grief. Pain must be acknowledged and resolved in order to move on.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 13. Which of the following types of care should the interdisciplinary team of hospice provide? Select all that apply.

A. Physical care available on a 24/7 basis B. Counseling on the addictive properties of pain-management medications C. Discussions related to death and dying D. Explorations of new, aggressive treatments E. Assistance with obtaining spiritual support and guidance ANS: A, C, E The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance.

Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying.

Support is also provided to client families.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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Chapter 38. Military Families Multiple Choice 1. Susan returned from active duty and is being treated for PTSD. She tells the nurse that she was never in a combat zone during her deployment, and her commanding officer told her that you cant have PTSD unless you were in active combat. Which of these responses by the nurse is an accurate reflection about PTSD in military personnel?

A. Women may experience other anxiety disorders but rarely experience PTSD as a result of being in the military.

B. PTSD after serving in the military is almost always related to trauma associated with active combat.

C. Women in the military more often experience PTSD secondary to sexual assault.

D. All of the above.

ANS: C Women are at risk for PTSD as a result of experiences in the military, and it is more often secondary to sexual assault rather than combat trauma. The other distractors are incorrect assumptions.

KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 2. Paulas husband returned from active duty 1 month ago, and Paula is now seeing a counselor for relational conflict in her marriage. She tells the counselor she thinks her husband cant love anything as much as he loves the military and that he acts like he cant wait to be redeployed. Which of these common aspects about military culture might be contributing to her husbands behavior?

A. Military mission is advanced as the highest priority.

B. Marriage is discouraged in the military.

C. Redeployment is considered the highest honor.

D. People who choose a military lifestyle often have asocial personality traits.

ANS: A One aspect of military culture is advancing the idea that the military mission takes precedence over other concerns, which could be perceived to include family and marital relationships.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 3. Joshua, a 15-year-old whose father has been suffering from PTSD since returning from combat, is now seeing a counselor himself with reports of flashbacks that are similar to his fathers symptoms. Which of the following interpretations of Joshuas behavior is supported by evidence?

A. Military children often pretend to have symptoms of PTSD to get secondary gains.

B. This is a common symptom of substance abuse and drug-seeking behavior.

C. It is not uncommon for children of parents with PTSD to experience secondary trauma.

D. Joshuas experience is indicative of impending psychosis.

ANS: C

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Children and caregivers of people with PTSD have been identified as at risk for similar PTSD symptoms as a result of secondary trauma.

KEY: Cognitive Level: Application | Integrated Processes: Caring | Client Need: Psychosocial Integrity 4. Bill is an only child whose parents are both career military personnel. He is being seen by the school nurse for complaints of fever and wants to be sent home. On examination he is afebrile. He tells the nurse he doesnt like this school anyway and the nurse notes that this is his third school transition in four years. Which of these understandings about the experience of military family members is important to providing compassionate care for this child?

A. Military children are more often exposed to unusual viruses, so he should be sent for a complete evaluation and bloodwork.

B. Military children are generally healthier than their nonmilitary peers, so he should be given strict consequences for pretending to be ill.

C. Children of military personnel are often victims of physical abuse, so he should be asked direct questions about whether or not his parents have been physically aggressive with him.

D. Isolation and alienation are common experiences of military family members, so it is important to assess further his adjustment in the current school setting.

ANS: D Isolation and alienation have been identified as a common experience of military family members. This experience may be exacerbated in children by frequent moves and changes in school environments.

KEY: Cognitive Level: Application | Integrated Processes: Caring | Client Need: Psychosocial Integrity 5. Carl is being treated for PTSD after return from military combat. He also sustained a mild traumatic brain injury secondary to an explosive device while in combat. The nurse decides to conduct additional screening assessments on the basis of common comorbidities that occur with these conditions. Which of these screening assessments would be relevant?

A. CAGE screen for alcohol abuse B. Beck Depression Inventory C. Mini Mental Status Exam D. All of the above ANS: D Alcohol abuse and depression are common comorbidities with PTSD. Cognitive deficits, including memory problems, may accompany traumatic brain injury, so all three of these screens would be relevant.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance 6. Mary is seeing her family physician for a routine checkup and mentions to the nurse that her husband just returned from active duty in the military. He was deployed to Iraq for the last 18 months, and Mary says she is very excited that they will finally be able to pick up where they left off. The nurse decides to ask more questions about their marital relationship in this post-deployment period. What is the best rationale for including these assessment questions?

A. The post-deployment period is often the most difficult time period for veterans and spouses to negotiate.

B. All veterans experience some PTSD and are unable to return to previous relationship patterns.

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C. Denial about the impact of combat experiences is common in military spouses.

D. Mary is most likely being abused by her husband and is covering this up.

ANS: A There is no evidence that denial is common in military spouses, and although physical aggression is a common symptom of PTSD, there is no report of PTSD symptoms in this case. Furthermore, not all veterans experience PTSD. However, knowing that the post-deployment period has been identified as the most difficult period for couples to negotiate, the nurse may find it beneficial to assess their relationship and provide an opportunity for education and resources as needed.

KEY: Cognitive Level: Evaluation | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance 7. The nurse is conducting an assessment for Don, a 5-year veteran with a traumatic brain injury (TBI). He was referred to the clinic for evaluation of movement disorders. He reports taking alprazolam (Xanax) for the last 3 months and wonders if that is contributing to his tremors and shuffling gait. Which of these understandings is most important in guiding the nurses further assessment and response to Don? A. Alprazolam (Xanax) has a high risk potential for extrapyramidal side effects.

B. Dons symptoms are likely related to alprazolam (Xanax) addiction.

C. There is an associated risk for Parkinsons disease in patients with TBI. D. Dons symptoms are most likely symptoms of PTSD. ANS: C There is an association between TBI and the development of Parkinsons disease. Antipsychotic agents rather than antianxiety agents have a higher risk for extrapyramidal symptoms. Although Dons tremors could signal drug withdrawal, the concurrent shuffling gait suggests a movement disturbance. Finally, movement disturbances are not a symptom of PTSD. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 8. Sam, a 50-year-old veteran with a traumatic brain injury (TBI), was recently diagnosed with Alzheimers disease. His sister asks the nurse, How can this be an accurate diagnosis? There is no incidence of this in our family. Which of these teaching points is accurate for the nurse to share with Sams sister?

A. Alzheimers disease doesnt tend to run in families.

B. Alzheimers disease is often misdiagnosed in patients with PTSD. C. Alzheimers disease is more common in patients with TBI than in the general population.

D. Alzheimers disease in patients with TBI is not like traditional Alzheimers disease.

ANS: C There is a 2.3 times greater incidence of Alzheimers disease in patients with TBI than in the general population.

KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 9. Brian is seeking treatment for PTSD following his tour of duty in a combat zone. He reports to the assessment nurse that he has been smoking pot and drinking alcohol daily for the past 4 days because he just cant stand feeling depressed all the time. Which of these assessments is the highest priority considering Brians

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symptoms?

A. Amount of current cannabis use B. Marital status C. Neurological assessment D. Suicide risk assessment ANS: D Because of a high correlation between PTSD, depression, substance abuse, and risk for suicide, the risk for suicide assessment is the highest priority to establish patient safety.

KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment Multiple Response 10. John is being treated for PTSD symptoms, which began shortly after his retirement from the military. He has had nightmares, flashbacks of traumatic events from combat, and episodes of acute anxiety. His wife is asking the nurse how he could be developing PTSD at this time when he hasnt been in a combat situation for over 10 years. Which of these teaching points are evidence-based pieces of information to share with Johns wife? Select all that apply.

A. Retirement has been identified as a common precipitating factor for PTSD. B. PTSD symptoms may develop at any time after a trauma.

C. PTSD is not the appropriate diagnosis, according to DSM-5, unless the trauma occurred greater than 5 years ago.

D. This is probably not PTSD but rather a brief adjustment reaction to retirement.

ANS: A, B Retirement has been identified as a common precipitating factor for PTSD, but symptoms may develop at any time. The DSM-5 establishes symptoms occurring and/or persisting beyond 3 months following a trauma as indicative of PTSD. KEY: Cognitive Level: Synthesis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 11. Les has been referred to the VA clinic because he was recently fired from his job. His former employer reported that he was drinking on the job and had become physically aggressive with one of his coworkers.

Which of the following statements during the intake assessment are consistent with common symptoms of PTSD? Select all that apply.

A. Ive been drinking and smoking pot more frequently in the past few months.

B. Ive always thought I was too good for that job anyway.

C. Sometimes I get so angry I just want to punch someones lights out.

D. I havent been getting enough sleep because the nightmares keep waking me up.

E. I dont like authority figures.

ANS: A, C, D

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Substance abuse, aggression, insomnia, and nightmares are all symptoms commonly associated with PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. Jane has begun treatment for PTSD with symptoms of depression. The nurse is reviewing the physicians orders. Which of these are evidence-based modalities for initial treatment of Janes illnesses? Select all that apply.

A. Acupuncture B. Electroconvulsive therapy (ECT) C. Sertraline (Zoloft) D. Cognitive behavior therapy (CBT) E. Propranolol (Inderal) ANS: A, C, D, E Acupuncture, SSRIs, CBT, and antihypertensives such as propranolol have been shown to be effective in treating symptoms of PTSD. ECT has not been identified as an effective treatment of symptoms of PTSD and would not be a first-line treatment for depression.

KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment: Management of Care